The presentation on Friday will provide you with a vaguely chronological overview of the recent massive Ebola epidemic in West Africa, which killed more than 11,000 humans and threw the fear of the viral god into every government on the planet. This material is taken from an unedited journal created during my work in West Africa in the fall of 2014. The presentation this Friday is given on short notice; that's my excuse for the, at times, disorganized nature of this material. Use the Bookmarks for better browsing. But, the included stories by various journalists, dedicated people who documented the epidemic, most often at significant risk to their own lives, is most excellent writing and portrays the profound manner in which Ebola affects individuals, families and entire nations. Browsing some of the included papers should reward most students who appreciate a good story. Richard Bargen, MD PS: Despite my most forceful resistence, I was forced, by persons unknown, to use the Comic Sans MS font.
Transcript
The presentation on Friday will provide you with a vaguely chronological overview of the recent massive Ebola epidemic in West Africa, which killed more than 11,000 humans and threw the fear of the viral god into every government on the planet.
This material is taken from an unedited journal created during my work in West Africa in the fall of 2014. The presentation this Friday is given on short notice; that's my excuse for the, at times, disorganized nature of this material. Use the Bookmarks for better browsing.
But, the included stories by various journalists, dedicated people who documented the epidemic, most often at significant risk to their own lives, is most excellent writing and portrays the profound manner in which Ebola affects individuals, families and entire nations. Browsing some of the included papers should reward most students who appreciate a good story.
Richard Bargen, MD
PS: Despite my most forceful resistence, I was forced, by persons unknown, to use the Comic Sans MS font.
significance in the interests of all humanity --- all this resulted in the creation of an extensive, though scattered, record of this Ebola epidemic in its early days. The human aspects of this roll-ing catastrophe are particularly well recorded, in my opinion, by writers and photographers who arrived early, with a sense of dedication, and then worked at some risk to themselves to create a record of this vast and deadly human struggle.
Chapter 7 is structured as follows. First, records that describe the course of the epidemic from December 2013 until September 2014 when I left for Liberia. Some of these records are scientific papers, research reports related to the epidemic. In addition, verbatim human interest reports from various media are included. They are ordered in a roughly chronological fashion. As I read these reports from the field written prior to my trip to Liberia, I was surprised at the con-centration of gifted writers who had confronted Ebola early on, and documented the nature of this epidemic. The record produced by a few dedicated photographers is also noteworthy.
The televised testimony of eye witnesses to the Ebola epidemic, left me convinced that something really bad, much worse than I'd imagined, was afoot in west Africa. The witnesses made it clear that even though the epidemic had been running out of control for nearly nine months, for the most part, the world was ignoring this human tragedy.
A major, unanswered question at the time was whether the anomalous behavior of Ebola in west Africa was due to an alteration in the Ebola virus, or it was the result of factors extrinsic to the virus. The answer to that question would have a large influence on the future spread of the epidemic and on the best way to end the human suffering.
During the summer of the hearings, the immediate task for the responders was to find some way to stop the spread of the epidemic. A secondary task at that time was to discern the factors that had allowed this nasty situation to arise in the first place, and then to create the nec-essary surveillance and alerting systems, which are essential to the goal of to ensuring such an epidemic will never occur again. This second task is of equal or greater importance, almost, than the first. It was the focus of my thoughts about the epidemic and formed the core of my motiva-tions for going to west Africa.
My early, continuing and powerful reaction on listening to the testimony of knowledgea-ble witnesses was how the heck did this situation get so out of hand? Where was the world? Where was I? Could this epidemic, and the consequent loss of thousands of lives, simply be the result of a failure in intelligence, the failure of humans in existing human organizations to com-petently surveil and alert the world to a global threat?
Although I kept my mind open, the picture presented to Congress by the witness testimo-ny certainly made it appear that we were dealing with a Mandemic, not an epidemic. I just made that word up, but it's meaning is probably clear to you. Consider a few selections from the wit-ness testimony in these hearing.
Mr. Isaacs discussed the reality of the epidemic, the terrible effects on it's human victims.
"...In the hours after death of Ebola, that is when the body is the most infectious because the body is loaded with the virus. Everybody that touches the corpse is another infection. We have encountered violence against us on numerous occasions by people in the general public when we have gone out at the request of the Ministry of Health to sanitize a body for a proper burial.
...One of the things that I recognized during the evacuation of our staff is that there is only one airplane in the world with one chamber to carry a Level 4 pathogenic disease victim. That plane is in the United States. There is no other aircraft in the world that I could find...
...There was a man, a Liberian-American, who came to ELWA Hospital with one of the most prominent physicians in Liberia, and that physician openly mocked the existence of Ebola. He tried to go into our isolation ward with no gloves, no protective gear. It is not an issue of gloves and a mask. It is an issue of no millimeter of your skin can be exposed or you will get sick and most likely die. That is sort of the reality of it.
Those two men left our hospital. They went to the JFK Hospital in downtown Monrovia,
where the doctor did examine Ebola patients, and he was dead 4 days later. The other man was dead 5 days later, but not before he went to Nigeria. And now there are cases of death from Ebo-la in Nigeria and there are eight more people in isolation..."
The fact this epidemic had grown to the extend it had without triggering a concerted, well resourced international effort to stamp it out, left him almost incredulous. His articulation of this amazing failure to respond, left me feeling puzzled, amazed and angry.
"The Ebola crisis was not a surprise to us at Samaritan's Purse. We saw it coming back in April. Our epidemiologists predicted it. By the middle of June, I was having private conversa-tions with senior government leaders and, by July, I was writing editorials in the New York Times saying that this was out of control.
In the 32 years since the disease was discovered, as I believe Dr. Frieden said a moment ago, there were a total of 2,232 known infections, which killed 1,503 people. Easily, this present outbreak is going to surpass that in fatalities as well as overall cases. It is clear to say that the disease is uncontained and it is out of control in west Africa. The international response to the disease has been a failure, and it is important to understand that. A broader coordinated inter-vention of the international community is the only thing that will slow the size and the speed of the disease.
...Liberia, Sierra Leone, and Guinea are poor. Like all countries, they have their problems with pointless bureaucracy, dysfunction, and corruption. I know for a fact that, in Foya, the se-cond largest center where Ebola is manifesting in Liberia, the workers at the Ministry of Health clinic were not paid for 5 months, even after the European Union had put money forward. The money just didn't get downstream.
...Again, I will say that Ebola is out of control in west Africa, and we are starting to see panic now around the world. People want to know. I don't know about you folks. I look at the Drudge Report. It can drive a lot of panic.
The ongoing global failure to respond has resulted in an unbelievable situation, in which responsibility for dealing with the human trauma of Ebola virus infection has become the respon-sibility of just two civilian relief agencies.
"If there was any one thing needed to demonstrate a lack of attention of the international community on this crisis, which has now become an epidemic, it was the fact that the interna-tional community was comfortable in allowing two relief agencies to provide all of the clinical care for the Ebola victims in three countries: two relief agencies, Samaritan's Purse and Doctors Without Borders."
TTEESSTTIIMMOONNYY DDRR.. FFRRAANNKK GGLLOOVVEERR
"This Ebola outbreak in Liberia has exposed the country's inherently weak health system. Less than 200 doctors existed in this country of 4 million prior to this epidemic. After the out-break in March of this year, that number plummeted to only 50 doctors. This occurred as a result of the exodus of 95 percent of the expatriate doctors.
After a second Liberian doctor died of Ebola, all of the government hospitals shut down. The patients are too terrified to enter the buildings. The nurses have stated they will not return to work unless they are issued adequate protection including gloves, gowns, and goggles.
At the ELW hospital in conjunction with Samaritans Purse, doctors and nurses continue to treat Ebola patients. There are 5 doctors and 77 nurses and aides. This is the only place in Monrovia where treatment for Ebola takes place. ... At the Phebe Hospital, the administrator came down with the virus, and he infected his 8 children, and his wife and all 10 of them died.
... If you read the Ministry of Health status reports that come out every day from Liberia, I don't mean to be dramatic, but it has an atmosphere of ''Apocalypse Now'' in it. There are bod-ies lying in the street. It is on the front page of the Wall Street Journal, and today, there are gangs threatening to burn down hospitals, and this is essentially a society that is, let us say, a generation from from a horrible war. Everybody had Post-traumatic Stress Disorder.
They can go from a normal conversation to a fistfight, to sticks, in the blink of an eye. So they have a lot of temperament and they have a lot of investment in what is going on. There is a lot of emotion. But it isn't just Liberia. It is Sierra Leone, it is all of these countries.
... One of the challenges we have in Liberia is after this 14-year brutal civil war, during that period of time people did not go to school. So you have a large population of illiterate peo-
ple and many of the languages in Liberia are not scripted, so you can't write something.
Dr. Glover spoke with almost painful understatement about the World Health Organiza-tion's involvement.
...I am all for building the capacity, but I think there needs to be something to augment their capacity. I think that there needs to be some kind of a coordination unit. I have heard here today that the World Health Organization has the lead; maybe, maybe not. I think that probably something perhaps with a bit more of an operational edge to it is called for. I don't know what that could be, but more is needed.
Senate hearings on the Ebola epidemic were held on September 16. Witnesses at this hear-ing left the powerful impression that a catastrophe was in progress. Please wake up world!
"In late March, we learned that there were cases of Ebola in our region, and we began preparing our staff and the ELWA facility so that we would be ready to care for patients in the safest way possible should the need arise. Three months later, our hospital had the only availa-ble Ebola Treatment Unit, also known as an isolation center, and I was one of two physicians to treat the first Ebola-infected individuals in southern Liberia.
From June 11 to July 20, the number of Ebola patients we saw increased exponentially. During that time, my organization, Samaritan's Purse, took over responsibility for all di-
rect clinical care of those infected with the disease. I was appointed Medical Director of what would become the only isolation unit in the Monrovia area. We opened a new, larger Ebola Treatment Unit and brought in patients from the government hospital. During that time, the number of cases continued to grow at an incredible rate.
Within days, our 20-bed facility was housing 30 patients, and there was no end in sight. The disease was spiraling out of control, and it was clear that we were not equipped to fight it effectively on our own. We began to call for more international assistance, but our pleas seemed to fall on deaf ears.
As the Ebola virus continued to consume my patients, I witnessed the horror that this dis-ease visits upon its victims -- the intense pain and humiliation of those who suffer with it, the irrational fear and superstition that pervades communities, and the violence and unrest that now threatens entire nations.
...This unprecedented outbreak began nine months ago but received very little attention from the international community until the events of mid-July when my friend and colleague, Nancy Writebol, and I became infected. Since that time, there has been intense media attention and therefore increased awareness of the situation on the ground in Liberia, Guinea, Sierra Leone and neighboring countries. The response, however, is still unacceptably out-of‐‐step with the size and scope of the problem now before us.
...I hope that the devastating impact of the current epidemic will result in new discoveries for treatments and vaccines in the future, but we cannot wait for a magic bullet to halt the spread of Ebola in West Africa. The current epidemic is beyond anything we have ever seen, and it is time to think outside of the box.
...Many Ebola-positive people are staying at home and even hiding when they become ill. Because of fear and superstition, their family members either abandon them or lovingly tend to them in ways that almost always result in the infection of the caregivers. We have to consider the role of home care as we seek to stop the transmission of Ebola.
...The World Health Organization has laid out a roadmap similar to what I have just de-scribed, but they are so bound up by bureaucracy that they have been painfully slow and ineffec-tive in this response. Their recommendations for home care were made August 28, and I am not aware of any significant progress in the implementation of their plan to date. It is imperative that the U.S. take the lead instead of relying on other agencies.
...Many have used the analogy of a fire burning out of control to describe this unprece-dented Ebola outbreak. Indeed it is a fire -- a fire straight from the pit of hell. We cannot fool ourselves into thinking that the vast moat of the Atlantic Ocean will keep the flames away from our shores. Instead, we must mobilize the resources needed to keep entire nations from being reduced to ashes.
Hearing witnesses, along with most experts on Ebola virus consistently emphasized that
the world could not sit back, try to wall itself off from the affected countries and expect a good outcome. Other than the unethical smell of such proposals, the principles of epidemic combat dictated that the resources of the world must be brought to bear on the epidemic in the place where it was currently thriving.
A fact that is in the show-stopper category, is the fact that currently affected countries do not have the resources to mount an effective anti-Ebola response. They lack the ability to track the spread of the virus. Lacking such basic capabilities means they are, alone, incapable of man-aging the epidemic, let alone stamping it out.
The virus had to be taken on directly on it's home turf. Dr. Dan Diekema, of the University of Iowa Carver College of Medicine:
“I think the primary effective measures are going to be in the outbreak zone. Bringing more resources to bear there to halt the outbreak. And that’s really going to be the key, that’s how we’re going to get rid of Ebola. The best preparedness here is to quell the outbreak there.”
Dr. Tom Frieden, director of the Centers for Disease Control, stated that the “most effec-tive method for battling the virus is sending trained professionals to the source.”
Chairman of the Joint Chiefs of Staff, General Martin Dempsey explained: “this needs to be an away game.”
By the time Congress held hearings on Ebola, it was known that in March 2014 a severe warning had been issued by MSF and the WHO had been put on notice of a deadly Ebola epi-demic gaining strength in the absence of any effective opposition. The warnings drew a yawn from international health officials. WHO trundled along for another six months before it pre-pared and released it's Ebola Virus Outbreak Response Plan. 2014 had become the Year of the Mandemic.
By early September I had decided to go to Liberia and see what was what, and do what I could do to help. I now had serious questions about the epidemic and it's etiology, and the need for answers motivated me as much as my desire to assist the medical responders to this epidemic.
I didn't want to be hooked up with a NGO, primarily because we needed the freedom of action to pursue our idiosyncratic goals in helping search out the origins of this epidemic and the factors that made it so unique, so unprecedented and so deadly. Also, I didn't have any conceits as to what positive impact I could have on this great disaster. I was just a guy who trusted his brain, who knew that a first hand view of the subject would bring an air of reality to his concep-tions.
The immediate task at hand for the entire world was, of course, was to stop this epidemic ASAP. The anomalous nature of the current epidemic raises serious questions about the possibil-ity of future outbreaks of Ebola, outbreaks of such severity that even today's disaster would ap-pear trivial by comparison.
Again, my primary interest related to the determination of any extrinsic factors which fa-cilitated the growth and spread of Ebola 2014. Once that is accomplished, the next key step is to implement a plan based on this knowledge, to realize the goal of preventing Ebola's next mani-festation --- Ebola 5.0 --- from ever occurring.
As essential as the need to stop this epidemic, is the need to delineate these factors and follow that up by establishing the surveillance systems, alerting systems, laboratory facilities, health care facilities, rapid response teams, necessary for early detection and take down of Ebola when the next outbreak begins -- terminate the outbreak before the victim count exceeds five
Much relevant information had been, and continued to be, gathered in the field. I needed to get up to speed, and though it was late in the game, the time had come to go. I was eager to be of service, armed with these theoretical questions which required evidence based answers.
My eagerness was matched by my naiveté, which I hoped would dissipate in the course of my self-underfunded mission [subsidized by a loan from my friend Steven Rothman].
After devoting a day to get into shape, I shouldered my backpack and departed for west Africa. Despite my non=affiliation with any organizations, I was backed by a strong team de-serving my thanks. The west Africa support team is composed of my three kids and their spouses along with my granddaughter. This team has mastered the art of sending me to disasters, they are experts in saying goodbye.
Their wonderful goodbyes, which become more delicious with every departure, have now reached a level of elegance which makes it exceedingly painful to leave. Seriously, one couldn't ask for a better send off. Over the years I've reached the point that if I haven't gone anywhere for a few months, I pack up and leave just to enjoy my team's goodbye celebration.
Between December 2013 and September 2014 in west Africa, a nascent epidemic intensi-fied and spread. From an epidemiological perspective, a key step early in the investigation of an epidemic is to discover the the index case. This determination often leads to understandings use-ful in the effort to stamp out the epidemic, and prevent future epidemics.
What information is available about the index case in the current epidemic and the nature of the sentinel event?
IINN TTHHEE BBEEGGIINNNNIINNGG IINN GGUUIINNEEAA
The epidemic had been running loose for several months before the specifics of the senti-nel event were determined. In late November 2013, unseen by the rest of the world, a little boy living in Meliandou, a remote village in southeastern Guinea, a small country in west Africa, be-came infected by Ebola. Unnoticed by most of us, he died on December 6, 2013.
Few if any made the connection between his death and the subsequent, sudden, unpleasant deaths of a few more villagers. Scattered funerals, more extensive human to human contacts, fol-lowed. From those small beginnings, a contagion began passing from one person to another, transmission occurring via simple physical contact between an infected person and a contact. De-spite the fact that nobody expects the Spanish Inquisition, by the middle of March 2013 there it was.
MMEELLIIAANNDDOOUU
Sometime in the spring of 2014, epidemiologists traced the epidemic's origins back to a 2 year old boy from the village of Meliandou. His name was Emile Ouamouno and he died on De-cember 6, 2013 becoming the index case in this outbreak. The cause of his death, at the time, was unknown.
The best depiction of this epidemic's origins, that I've come across, is the excellent ac-count by Jeffrey E. Stern in Vanity Fair. Stern describes the death of 2 year old Emile Oua-mouno and then proceeds to lay out the evolution of the epidemic during the early part of 2014.
A significant milestone occurs on March 23. On this date the WHO was informed of a spreading Ebola epidemic in Guinea, associated with a growing death toll. In retrospect it ap-pears that this warning was filed and forgotten.
The village of Meliandou [above] is located within the Guinean forest region, approx-
imately 100 miles from Monrovia. The view is towards the southwest.
It might have ended there -- one child's death in the jungle, way back in December -- with no one ever to know that Ebola had spilled over into the human population. Certainly this hap-pens often -- spillovers that produce outbreaks so sudden, and generally so remote, that they don't spread. People close by attribute the deaths to some other, more common affliction, while people far away never hear about them at all.
In this case, however, a family dispute intervened. After the child was infected but before he died, the mother, who happened to be pregnant, packed up the boy and a daughter and marched across the village to her own mother's house. Space there was tight, because the grand-mother had a houseguest. Beds were shared, and the baby's symptoms exploded. His mother was infected, his sister, his grandmother, the houseguest too. When the mother miscarried, the mid-wife was infected. The Ebola virus had started to move.
Above: A GE image of the village of Meliandou, Guinea.
When Ebola strikes, it kills quickly, but it can take up to three weeks to incubate, and usu-ally around 10 days. The period is long enough that contact with a possible source may have been forgotten, and long enough for infected people to travel without symptoms. And even if you tested for Ebola -- which nobody in Guinea had the capacity to do -- you wouldn't find it during the incubation period: Ebola can't be detected in the blood until symptoms show. [Note: Ebola can be detected in the blood at least a day prior to the onset of symptoms.]
An epidemic can start slowly and go unnoticed for weeks. This has never been much of an issue before, because Ebola tends not to find its way into large population centers, or places where people are very mobile. This time would be different.
On January 24, more than a month after the first infection, Jean Claude Kpoghomou, a doctor in the town of Tekolo, called a superior to report on something strange happening in a vil-lage under his jurisdiction. Three patients had died in the span of two days, he said. All of them came from the same village, a place called Meliandou. The symptoms looked like cholera: diar-rhea, vomiting, extreme dehydration.
...Dr. Kpoghomou's superior forwarded the alert from Tekolo on to the health department's prefectural authority in Guéckédou. Guéckédou sent the alert up to the regional director of health in Nzérékoré, who sent it on to the Ministry of Health in Conakry, the country's capital, a city of a million and a half on the coast several hundred miles away. The national government had now been alerted: a potentially serious crisis was developing down in the Forest Region.
Amid the constellation of public-health crises that Guinea must contend with -- under-resourced and overburdened as it is by a constant onslaught of ordinary killers like malaria, tu-berculosis, and automobiles -- it was not surprising that three deaths in the Forest Region did not warrant immediate intervention. But officials in Guéckédou organized their own small investiga-tive team and dispatched it to Meliandou.
...Until its final stages, Ebola can easily be mistaken for cholera. It can also look a lot like malaria, another long-tenured killer in Guinea. What no one has ever died of, anywhere close to Guinea, is Ebola. The last big Ebola outbreaks--in Uganda and the Democratic Republic of the Congo in 2012 -- were more than 2,000 miles away. They might as well have been in another world. If you'd told any of the investigators, as they considered the crisis developing in Meli-andou, that they were looking at Ebola, they either would not have believed you or, just as likely, would have asked you what Ebola was.
On January 26, officials at the prefectural health authority held a meeting in Guéckédou. They now knew that something was wrong in Meliandou, but they didn't know what. They con-sulted foreign health professionals stationed in town; Doctors Without Borders, had a malaria project there.
Officials decided to make another visit to the village, this time with a more experienced medical team, on January 27. For a second time, health workers stood at the epicenter of the Ebola outbreak, and for a second time they did not understand what they saw. By now there had been eight Ebola infections and seven deaths. Meanwhile, the virus had slipped out of the vil-lage. When the grandmother of the infant victim fell sick, she decided that the way the villagers were approaching the illness -- summoning a shaman to brandish his fetishes and work his spells --was not satisfactory.
Above: A GE image depicting the capital of Liberia -- Monrovia -- and the capital of
Sierra Leone -- Freetown -- in relation to Meliandou and other locations mentioned in Stern's narrative.
The grandmother had a friend in Guéckédou who was a nurse, and when the grand-mother's symptoms began to worsen, she went to see what real medicine could do for her. The nurse tried to help, but he had no idea what he was dealing with. The grandmother went back to Meliandou, where she died.
In early February, the nurse himself developed a fever. Now the virus was in Guéckédou, a bustling trading hub where people converge from Liberia and Sierra Leone. When the nurse's condition deteriorated, he sought help from a friend who was a doctor in Macenta, in the next prefecture over. The nurse stayed just one night in Macenta--sleeping in the doctor's own house, sharing a room with the doctor's own son -- and died the next day,
FFEEBBRRUUAARRYY 1100
The doctor in Macenta was shocked. He didn't know what he had just witnessed, but it was unlike anything he had seen before, and he immediately sent an alert to the regional director of health in Nzérékoré. Then the doctor developed a fever. He set off for the capital, where he hoped someone might have answers.
But along the road--a jolting, treacherous passage lined by burned-out cars and always a few freshly rolled tractor-trailers spilling timber -- the doctor died. His body was sent to Kissi-dougou, a city of more than 100,000, where a funeral was held. Before long, Kissidougou was experiencing an outbreak of whatever it was that had killed the doctor.
... Nzérékoré had just received a report from Macenta, which was reeling from its own tragedy. The doctor who had fallen ill and died on the way to Conakry -- he was just the begin-ning. Mysteriously, the doctor's son had also died, and a colleague of the doctor's who worked in the hospital lab, along with two of the doctor's brothers and a nurse he had treated. Something was killing people in Macenta. Nzérékoré compiled a report on the two separate crises and sent it up to the capital.
In Conakry, news of a doctor's death was finally enough to register with the authorities. No one yet knew, but by now Ebola had claimed close to 30 lives and was continuing to spread -- to Dandou Pombo, Dawa, Gbandou, Farako, and Baladou. The Ministry of Health and the country office of the World Health Organization set up a joint investigation, sending medical personnel to record the symptoms and backgrounds of patients who had died in Macenta.
In the process, the team discovered that one of the victims -- the nurse -- didn't live in Ma-centa but rather had come from Guéckédou. This was a crucial fact: the team began to suspect that the separate crises in Macenta and Guéckédou were not separate at all.
...What finally gave the virus away was, of all things, hiccups. On March 14, M.S.F.'s Ge-neva office received a report from a medical investigation in Guinea. M.S.F. Geneva immediate-ly forwarded the report to Dr. Michel Van Herp, an epidemiologist in its Brussels office, and one of the world's leading experts on Ebola.
When Van Herp opened the document, what immediately jumped out at him was that half the victims had developed hiccups. For reasons not entirely clear to the medical community, hic-cups are associated with Ebola.
It is definitely a hemorrhagic fever," Van Herp told a colleague in Geneva, who was con-sulting with him by phone. "But we must really take into consideration that it is worse than Las-sa. I think it's Ebola." Van Herp notified M.S.F.'s Brussels headquarters, presented his suspi-cions, and then immediately began preparing to leave for Africa.
[March 22] ...Later that day, at seven P.M., the worst was confirmed: the samples were positive for Ebola. The lab notified M.S.F., which notified its team on the ground and the gov-ernment of Guinea. On March 22, more bad news came from the lab. The samples from Guinea were the Zaire strain, the deadliest known version of the virus...
So, in mid-March the Guinea government announced that a small outbreak of Ebola virus had occurred in the Guekendou district. By then, the number of cases far exceeded those official-ly tallied. The disease spread rapidly to major population centers. By the time official score was kept, the Ebola epidemic had already outrun any possible efforts that could be made to combat it using regional resources.
[The GE image below with a view to the northeast, depicts the capital cities of Guinea, Sierra Leone and Liberia. The small village of Meliandou, Guinea, is the location
where the first case of this Ebola epidemic was recorded in early December, 2013.]
The Ebola epidemic warning received by WHO and the regional governments in March,
was backed up by a warning from MSF to everyone who would listen [a very short list] that west Africa was facing a dire, potentially catastrophic situation. Without a major input of human and material resources, the growing Ebola epidemic would quickly overwhelm the health care re-sources of the region. The out of control Ebola epidemic would take existing resources, chew them up and spit them out. This was a critical time, a time for action.
This was a time described by the epidemiological side of Shakespeare when wrote: There is a tide in the affairs of men, Which taken at the flood, leads on to fortune. Omitted, all the voyage of their life is bound in shallows and in miseries. On such a full sea are we now afloat. And we must take the current when it serves, or lose our ventures.
Months after MSF issued it's warning, studies of epidemic data strongly corroborated the essence of the MSF warning -- we have just a short window of time in which a major increase in anti-Ebola efforts will bring this epidemic to a halt. If we wait, if we delay, all bets are off.
The studies referred to calculated a key descriptor of an epidemic, the R0. The value of R0 tells you whether the epidemic is capable of rapid spread, of running away from you, or if it is amenable to countermeasures which can bring the outbreak to a halt. The R0 for the 2014 Ebola epidemic in March 2014 suggested that the outbreak was susceptible to being extinguished if a modest increase of resources and effort were thrown into the battle.
It never happened. MSF's warning was followed by a long metaphorical silence marked by the WHOs failure to effectively act, the inability of regional governments to ratchet up their game, and the epidemic growing too large to control with any regional strategy. Three months passed, time during which the epidemic relentlessly expanded. By July, WHO and the regional governments realized that what MSF had warned of, had come to pass. They were in the midst of a ferocious, deadly Ebola epidemic, an epidemic so out of control that even if WHO and the re-gional governments finally did act, all the kings horses and all the kings men could not put Ebola virus back in the bottle again.
The situation in west Africa was now a threat to global health and security. This transfor-mation is graphically depicted below.
The graph below tally's the number of Ebola cases and deaths officially counted from March to the end of October. The vertical axis represents the number of persons affected, the horizontal marks the dates. The linear depictions are coded to depict Ebola cases, Ebola deaths, and the country involved.
The actual number of cases and deaths are at least twice the reported numbers. The epi-demic was running it's own race, and was obviously out of control.
Again, one key question is why the early Ebola deaths not set off any alarm bells in the
outside world. The deadly virus spreading in Guinea shouldered undetected for three months. Early on, regional hospitals, unaware of the nature of the disease they were dealing with, quickly became Ebola incubators.
Health workers, nurses and doctors who initially believed they were dealing with cholera
or Lassa fever, began falling ill and dying after having personal, unprotected contact with Ebola infected patients. Of the first 15 people to die in this Ebola outbreak, 4 were health care person-nel.
VVOOYYAAGGEERR 11
I'm not sure why -- perhaps it's because I don't have a wrist watch -- I fell into the habit of gauging the passage of time using the speed of the Voyager 1 satellite as a metric. Since it's launch in 1973? Voyager 1 has journeyed ever farther from the earth, traveling about 65,000 kil-ometers per hour. At that speed, the satellite puts another 3.6 AU between itself and earth every year. Thus, in 2014 while working on the MorningStar manuscript, I might work for 2 million miles before taking a break. Or if I was feeling lazy, 100,000 miles investment of time would do. The actual distance of the satellite from earth, marked in real-time is available on a JPL website.
Voyager 1 is moving out of the ecliptic plane, departing at an angle of approximately 35 degrees to the north. It will take an estimated "300 years for Voyager 1 to reach the inner edge of the Oort Cloud and possibly about 30,000 years to fly beyond it." In about 40,000 years, Voyager 1 will pass within 1.6 light-years of AC+79 3888, a star in the constellation of Camelopardalis.
Voyager 1's 'companion satellite [Voyager 2] is heading out of the solar system also, but is leaving the ecliptic in a southerly direction. Voyager 2 will pass 1.7 light-years from the star Ross 248 in about 40,000 years. Then, in 296,000 years, it will pass 4.3 light-years from Sirius, the brightest star in the sky. The Voyagers likely will journey through the Milky Way. They may still exist in 5 billion years from now, when our sun expands and engulfs our earth.
I like to imagine I'm a passenger on the Voyager 1 satellite [which I've written about else-where]. My status as a passenger on Voyager 1, provides me with a relaxing perspective on daily earth life. During the summer of 2014 I was along nearly 20 billion kilometers from earth. From this distance, most of my earth troubles were entirely invisible. But the when the Ebola epidemic entered my consciousness, and I became aware of all the human suffering associated with it, that sight was not attenuated by the vast distance between Voyager 1 and earth. The epidemic sud-denly felt right in my face.
If this little imagining seems peculiar to you, well it's because it's private and wasn't in-tended for an audience. At times in Liberia, observing severe human suffering and distress, I would wonder about how so much trauma could be encompassed on this tiny globe that is invisi-ble to the eye from where I usually sat.
Let me also make a point about the people in west Africa who are suffering the Ebola on-slaught. Everyone I met was just like me or my family or my friends or the people I work with. They are energetic, ambitious and intelligent humans, quite different than the imaginary generic residents of remote villages in underdeveloped nations. The kids are exactly like your kids, they love and laugh and are cherished just like your kids are. At any time, any person mentioned in this account, any person you read about in news accounts, could sit down and Skype with you, no more distant than your kids in the next room. This immediacy gives me a greater sense of humanity than previously. It also increases the pain when you are a witness to the suffering of others.
Based on the previous paragraph, I can see why I've never been accused of being a philos-opher [or a writer, for that matter]. I hope you get my point however. Next, let me make a few comments about me and Ebola.
DDRR.. DD.. HH.. SSIIMMPPSSOONN
In 2014 I had some familiarity with EVD. Many people did. The existence of a nasty bug, the Ebola virus, had seeped into the the consciousness of people around the globe to a certain degree, over the decades since it's first outbreak in 1976.
In the late 90s, when Bart Simpson was confined to bed by an illness, his mother brought him a book to read, to pass time during his convalesce --- "Curious George and the Ebola Vi-rus."
Back in 1979 I was living in London, studying in pursuit of a diploma in tropical medicine at the London School of Hygiene and Tropical Medicine. The London School of Hygiene and Tropical Medicine is a stolid, massive looking building seemingly designed to weigh down the corner of Keppel and Gower Streets and keep this small patch of England from floating off into space.
One of my most memorable lecturers was Professor D. Simpson. Dr. Simpson was one of the first medical people in the world to encounter the Ebola virus. In the late summer of 1976, a mysterious outbreak in southern Sudan killed several hundred human beings. The agent respon-sible for this frightening occurrence was unknown. Dr. Simpson was tasked by WHO to go to southern Sudan and figure out what was killing the populations of towns like Maridi, Juba and Nzara. In the classic scenario wherein everyone is running in one direction, Dr. Simpson in his space suit is walking in the other direction, heading into the inferno.
Dr. Simpson stood at the front of the rustic lecture hall in the London School of Tropical
Medicine and Hygiene and told a tale of horror and heroics that sent a chill down my spine.
His was a prepared scientific mind but under the circumstances, it had to be supplemented by a boat load of courage in order to complete this mission. I have since held the opinion that Dr. Simpson is one of the bravest people on earth.
London School of Hygiene and Tropical Medicine
Professor Simpson worked with a small group of professionals who were tasked with fig-uring it all out. All they knew was that the alarming events reported to authorities were different than any ever reported in the history of medicine. They also knew that the population in the re-gion had been savaged. Those still alive had fled into the hinterlands. No one was willing to fly them into the afflicted region so some ingenuity was involved in getting into Maridi.
His account about his experience of tracking down this incredibly lethal virus in southern Sudan were beyond memorable. He was not a man given to exaggeration, but his soft spoken lec-tures chillingly portrayed the horror film-like experience of searching a town abandoned by the living, for the killing agent. Autopsies performed on bodies laying in the streets, kneeling in the dirt in his spacesuit, wondering about the unknown cause of the death that surrounded him.
Dr. Simpson's straightforward account of the vital epidemiological work he did in Sudan, truly sent a chill running through the lecture hall. I've never attended any lecturers before or since which put the fear of god in me like Dr. Simpson's lectures did. Today, when my relatives go to the theater to see "Invasion of the Body Snatchers" I can stay home and have the same scary experience just by remembering some of Dr. Simpson's slides taken during the world's first Ebola outbreak.
Since the two outbreaks in 1976 -- one in Sudan and the other in Zaire -- there have been approximately 30 more Ebola outbreaks in central Africa. Usually, after killing anywhere from a handful to a few hundred residents, the outbreaks have faded away. Where the virus fades to, no one ever discovered, to this day. Between outbreaks in human populations, Ebola virus resides quietly in some tolerant reservoir in the jungles of central Africa.
Then, some combination of circumstances brings the filovirus into contact with human be-ings and the resulting Ebola infection tends to be horrible, violent and deadly. Much of the in-formation below, on the first Ebola outbreak, is taken from the report to WHO from specialists, including Dr. Simpson, who investigated the epidemic in the Sudan. A separate team investigat-ed the outbreak in Zaire which began within a month of the Sudan outbreak.
The first known outbreak of Ebola Virus Disease [EVD] occurred between June and No-vember 1976 in Nzara, South Sudan. This first outbreak on earth was caused by Sudan variant of Ebolavirus. The Sudan outbreak infected 284 people and killed 151: 67 cases in the source town of Nzara, 213 in Maridi, 3 in Temburq, and 1 in Juba.
The index case in Sudan was the storekeeper in a cotton factory in Nzara. He became ill on June 27, 1976 was hospitalized on 30 June, and then died on 6 July. Dr. Simpson and others involved in the Sudan outbreak were aware that they were dealing with a heretofore unknown disease. Actual "positive identification" and naming of the virus did not occur until some months later in the Democratic Republic of the Congo.
The epidemic in Maridi was amplified by transmission in a large, active hospital. Trans-mission of the disease required close contact with an acute case and was usually associated with the act of nursing a patient.
NNZZAARRAA
The origin of the world's first Ebola outbreak was the small town of Nzara. Located in southern Sudan, Nzara was basically and extended clusters of houses scattered in the dense woodlands bordering the African rain forest zone. The total population of the area within 10 miles of Nzara is estimated to be about 20,000, most of whom live in mud--walled thatched-roof houses surrounding the town proper. The main employer in Nzara is a large agricultural corpora-tion which has 2,000 employees, half of whom work in a large cotton factory in the town. The corporation has excellent records of employee absenteeism which facilitated the epidemic inves-tigation. A small hospital was operative in Nzara, but at the time of the outbreak the facilities were limited and few patients were admitted.
Investigation of factory records for the previous two years did not reveal any fatal hemor-rhagic disease in Nzara until late June or early July, 1976. Beginning in June, one or two factory workers per week started dying of hemorrhagic disease. Their families and friends, those who cared for them, would subsequently manifest the same symptoms and frequently die. By the first week in September, six factory workers and 25 of their contacts had developed the same syn-drome and 21 had died.
The only link between primary victims was work the cotton factory. Investigators
searched for an animal reservoir of infection, but none was discovered. The outbreak in Nzara continued on until late October infecting a total of 67 people of whom 31 (46%) died. .
MMAARRIIDDII
During the outbreak in Nzara, the virus was exported to another town, Maridi. Maridi, a town with an estimated population of 10,000 with another 5,000 people in its environs, is located about 180 km east of Nzara. The hospital in Maridi, in contrast to the one in Nzara, is an actively practicing hospital with a large staff [total 230].
There was seldom any problem in determining the source of infection for a case. Usually, the possible source (or sources) was well known to the patient being investigated. In Maridi sources were determined for all but five of 203 investigated patients, By contrast in the Nzara outbreak 14 of 67 (21%) cases had no contact.
Transmission of Ebola virus from person to person, has required close and usually pro-longed contact with an acutely ill patient. Transmission did not seem to occur via the airborne route. Actually nursing an active case greatly increased the chances of becoming infected (81%).
The outbreak in Maridi demonstrated a lesson that unfortunately seems to required repeat-ed teaching over the years; a hospital is an ideal environment in which to transmit disease. One third of the medical staff at the Maridi hospital became infected by Ebola. 41 staff members died. All of the 6 medical assistants were infected and 41% of the student nurses. Just as occurred in the 2014 outbreak, in the days and months before the Ebola virus was recognized, infected pa-tients were not isolated. Maridi hospital was in chaos. Of the 213 patients in Maridi, 93 acquired their disease in the hospital. Most of these (72) were hospital staff infected during their duties.
The control of this outbreak in the Sudan relied on the classic public health principles of identification and isolation. The outbreak in Nzara died out spontaneously. However, the out-break in Maridi required intervention. Strict barrier nursing was established initially in early Oc-tober, 1976 and reinforced with addition al disposable isolation equipment in mid-October. In early November, surveillance teams were established to search house--to--house in Maridi and any patients discovered were placed in a specially constructed isolation ward. With time, the sur-veillance was expanded to include most of Western Equatorial Province. The last known case in Sudan occurred on November 20, 1976.
SSUUBBCCLLIINNIICCAALL IINNFFEECCTTIIOONNSS
The obvious question as to if Ebola virus first appeared now, was it a visitor from space, or was it a virus that normally didn't infect humans and usually quietly resided in some unknown animal reservoir in the region. If the latter, that would suggest that humans in the region likely were infected by Ebola from time to time but when they were, they sustain subclinical infections, or suffered illnesses that were relatively moderate, but survived.
This latter possibility is supported by post-epidemic epidemiological studies. They showed for example, in Maridi of those people who were case contacts, in hospital and in the local community, who had not obviously contracted Ebola virus, 19 % nonetheless bore antibod-ies to Ebola. They'd been infected by Ebola but the illness resulting had been mild or even sub-clinical.
In Nzara, where the prime source of Ebola infection was the Nzara Cotton Factory, 37 % of the workers who did not get ill, had antibodies to Ebola virus. That's amazing.
Discussed in more detail below is the second outbreak of Ebola virus which began in the Bumba Zone of Zaire about a month after Ebola had appeared in Nzara. Despite extensive ef-forts, the exact link between viral haemorrhagic fever in Nzara, Sudan and Bumba Zone, Zaire, remains undetermined. Nzara is 427 miles as the crow flies, from Yambuku. Extensive commer-cial traffic moves between the two.
Investigators discovered one truck driver in Nzara who personally escorted an early case in Nzara to hospital on July 24, 1976 with the help of two other friends. The two other friends both developed disease respectively on the 1st and 3rd of August 1976 and died 10 days later. The driver left the day after aiding his friend and arrived in Bumba 4 days later.
CONTROL OF FIRST KNOWN OUTBREAK OF EBOLA VIRUS
He stated he had no disease and that he knew of no one who travelled with him who had become ill. It is very possible that several other people who had had similar close contact with sick patients travelled from Nzara to Zaire during the course of the outbreak in Nzara. One of them may have become ill and set up a secondary chain of infection in Zaire.
Relative locations of key centers of Ebola outbreaks
On 26 August 1976, a second outbreak of EVD began in Zaire, west of Nzara. The index case appeared in the small rural village of Yambuku, in the form of village school headmaster Mabalo Lokela, who began displaying symptoms on 26 August 1976.
Lokela had returned from a trip to Northern Zaire near the Central African Republic bor-der, having visited the Ebola River between 12 and 22 August. On September 5, as his illness worsened, he was admitted to Yambuku Mission Hospital. Lokela died on 8 September, 14 days after he began displaying symptoms.
Not long after Lokela's death, many of those who'd been in physical contact with him also began dying. This mysterious contagion caused significant panic in the small village of Yambu-ku. The government of Zaire declared the entire region a quarantine zone. No one was permitted to enter or leave the area, with roads, waterways, and airfields placed under martial law. Schools, businesses and social organizations were closed. Researchers from the CDC, including Peter Piot, travelled to Yambuku to investigate the viral outbreak.
When all was said and done and the outbreak had ended, the virus had infected 318 hu-mans and killed 280 of that group (a 88 percent fatality rate). Although it was assumed that the outbreaks in Sudan and Zaire were connected, they were caused by two distinct Ebolaviruses, SUDV and EBOV.
The international investigatory commission also drew a conclusion that remains highly relevant to the Ebola outbreak in 2014. They concluded that an Ebola outbreak illustrates the need for national disease surveillance, the prompt solicitation of international assistance, and the need for the development of international resources, comprising personnel, equipment, transport, communication, and finance, that can be made available in a very few days to cope with such emergencies.
Dr. Piot's account of his involvement in the investigation of the Zaire outbreak, is much more interesting that the official post-investigation report. Below, segments from Dr. Piot's ac-count.
...The next morning the pilot smoothly navigated our DC-10 into Ndjili airport in Kinsha-sa, where we parked near several wreckages of less fortunate airplanes. I pushed to the front of the plane to find Lelievre-Damit, and glued myself to him when descending the DC-10 stairs, as tightly as a baby monkey clings to his mother. To be honest, I wasn't just bewildered and hung-
over: I was slightly afraid.
The roads of Kinshasa were unbelievable, with people and animals wandering randomly across them, not to mention the vehicles, which hurtled from every direction. We drove straight to a meeting at the headquarters of the Fométro, the Fonds Médical Tropical, a nongovernmental organization that operated much of Belgium's vast program for medical aid in Central Africa.
American Karl Johnson -- head of Special Pathogens at the Center for Disease Control (CDC) in the U.S. rapped us to attention -- it was clearly his meeting -- and summarized the situ-ation in a few words. We were dealing with a virus that was completely new to science. Its po-tential for transmission -- particularly to medical teams and caregivers -- appeared to be extraor-dinarily dangerous.
Reports claimed that more than 80 percent of people infected were dying. We had only one possible treatment option in the form of serum from convalescents who had very high levels of antibodies, but we needed to track down such individuals, test their blood to be sure it didn't contain live virus, and then treat it to be able to inject antibodies into people currently sick. He went on: the worst scenario we faced was the specter of a full-blown epidemic in Kinshasa, an unruly megacity with poor infrastructure, an unreliable administration, and 3 million citizens ac-customed to defying arbitrary government controls.
Barely a fortnight before, three people from the Belgian mission in Yambuku-- two nuns and a priest -- had been brought to the capital for treatment. All were now dead, and they had infected at least one nurse, Mayinga N'Seka, now hospitalized in critical condition. Efforts were being made to track down all her contacts in the city to quarantine them. They included -- here Johnson paused for a second --personnel of the US Embassy, where the nurse had recently final-ized arrangements for a student visa to the United States.
Was this the beginning of an outbreak in Kinshasa? Once a virus this lethal is introduced into an environment this chaotic, it is almost impossible to control it. It is also an explosive polit-ical situation for the government, and it was clear from the health minister's agitation that news about the epidemic was out and panic was already setting in.
...A determined Flemish man appeared, perhaps 10 years older than I, wearing dark glass-es and a local shirt made of African wax material. He introduced himself to us: Father Carlos, from the Order of Scheut, thus a colleague of the Catholic missionary priests who had died of the virus in Yambuku.
Father Carlos briefed us about the epidemic. It had all started in Yambuku in the first week of September, when the headmaster of the mission school, who had been traveling through the north on vacation, returned and fell ill. After his death, crowds attended his funeral, and with-in days the mission hospital began filling with other sufferers, including the headmaster's wife.
They suffered high fever, headache, hallucinations, and usually bled to death. One after another, his caregivers at the Yambuku mission hospital fell ill, along with members of his fami-ly, other patients, and dozens of other, apparently unrelated, people.
Nobody knew how many people had died, but all those who fell ill died within eight days. The few nuns still alive at the Yambuku mission were convinced they too would die soon. Only one person was known to have recovered from the virus. As for current cases, there were some in Bumba, and several people who had traveled to Bumba from Yambuku and were being kept in quarantine.
By the time we left for Yambuku we had heard of well over a hundred fatalities. My natu-ral skepticism began to fall away, replaced by doom. The stories of Father Carlos and Dr. N'goy, the District Medical Officer who had first identified the epidemic, the reports at the Bumba hos-pital, the evident fear of the pilots and the townspeople of Bumba and their desperate attempts to flee the town ... the apparent virulence of this disease, the high mortality -- put together with the poverty and poor organization that characterized Zaire and the potential for contagion in Kinsha-sa--added up to a picture that Joel Breman, a CDC senior epidemiologist, summarized as "poten-tially the most deadly epidemic of the century."
...The thick green curtain around the road closed in again, and we advanced with great dif-ficulty until first the coffee plantations and then the church and red roofs of the Yambuku mis-sion appeared, like mirages, in the blinding sunlight. Surrounded by a neatly swept courtyard lined with royal palm trees and immaculate lawns, they seemed surreal. It was difficult to believe that this clean, orderly, even idyllic place was really Yambuku, the heart of the mysterious killer virus.
The nuns were staying in the guest house in between the fathers convent on the right, and the nuns convent and school, on the left. As our group walked up, Sister Marcella, the mother superior, shouted, "Don't come any nearer! Stay outside the barrier or you will die just like us!"
Although she was speaking French, I could hear from her accent not only that she was Flemish, but also the region that she was from, near Antwerp. I jumped over the line of gauze bandage that had been strung up to warn away visitors and shook her hand. In Flemish, I said, "Good day, I'm Dr. Peter Piot from the Tropical Institute in Antwerp. We're here to help you and stop the epidemic. You'll be all right."
There was a very emotional scene as the three nuns, Sisters Marcella, Genoveva and Mariette, broke down, clinging to my arm, holding each other and crying helplessly as they all began talking at once. Watching their colleagues die one by one had been an appalling experi-ence.
Later the sisters told us that they had read that in case of an epidemic, a cordon sanitaire had to be established to contain the spread of the disease. They had interpreted this literally, with an actual cord that they strung around the guesthouse where they had taken refuge. They had also nailed to a nearby palm tree a sign in Lingala, warning "Anybody who passes this fence will die." It instructed visitors to ring a bell and leave messages at the foot of the tree. It was scary and sad and spoke volumes about the fear that they had endured.
CCOORRDDOONN SSAANNIITTAAIIRREE
Leaving Dr. Piot's narrative for a moment, let me comment on the cordon sanitaire. This is an old concept for fighting and containing epidemics like the bubonic plague.
The term first appeared in 1694 in a plan published by Fillip Arrieta, the royal auditor for the province of Bari, Italy. Arrieta had been actively involved during the plague years of 1690 to 1692, in establishing a sophisticated quarantine system, a pervasive surveillance system, along with support programs to maintain life in affected cities. Even though the source of various plague was unknown at the time, the behavior of epidemics allowed certain deductions to be made about the best way to contain and stamp out an epidemic. Arrieta recorded his approach on a couple of maps which still exist.
Based on observations and intuition, Arrieta decided that the progress of a contagious disease could be stopped by implementing two complementary spatial strategies. Implementation of these strategies required strict adherence to Arrieta's instructions. Essential to the eventual success was the maintenance of order in cities suffering contagion.
Arrieta's first spatially grounded strategy was to create a defensive cordon sanitairé, es-sentially walling off the affected areas, prohibiting all travellers and intercourse between affected areas and regions free of disease. The second aspect of what really was one strategy, involved taking active steps, a sort of offensive isolation, to ensure that regions with infection were com-pletely isolated from surrounding disease free regions.
His strategy resulted in the chains of transmission between humans, to be broken. As a consequence, the contagion died out. To a certain extent, these concepts are similar to that used by Dr. Henderson who used "ring vaccinations" to attack smallpox and eventually wipe it from the face of the earth.
DDRR.. PPIIOOTT IINN YYAAMMBBUUKKUU
As Sister Mariette prepared dinner for us, Sister Marcella showed us the notebooks where she had recorded all the deaths of hemorrhagic fever patients, and any data she felt was relevant to their illness, such as recent travel. Nine out of 17 hospital staff had died, as had 39 other peo-ple among the 60 families living at the mission, and four sisters and two fathers. She broke down several times as she described their symptoms and the agony of their deaths, particularly those of her fellow nuns.
Sister Marcella continued reading out from her neatly kept records as I scribbled down more precious pieces of information. She listed the names of villages where deaths had occurred. She wondered whether the illness might be linked to eating fresh monkey meat: the villagers of-ten foraged for food in the forest and the headmaster who was, tentatively, our "Patient Zero" had returned from his travels with several monkey and antelope carcasses. She noted a high number of deaths among newborn children born at the mission clinic, and observed too a sudden spike in stillbirths among their herd of pigs.
Three months ago, she said, there was an epidemic among goats in the region of Yandon-gi. These were all good lines of inquiry. (Later I took blood from the pigs through their tail veins, a new experience for me.) None of them panned out exactly, but another of Sister Marcella's hy-potheses proved to be exactly right.
"Something strange must be happening at the funerals," she told us. "Again and again we've seen that the funerals have been followed a week later by a batch of new cases among the mourners."
She was clearly pleading with us for answers, but there was nothing we could say. Our first job was just to ask questions. To break the ice I showed the electron microscope photos of the new virus, as I later did in every village we visited. The sisters too were fascinated by the wormlike structures that had caused so much pain and devastation in their community. As we had no clue how the virus was transmitted, and whether the virus could somehow survive on ma-terials such as mattresses and linen, we decided to sleep on the floor of a classroom in the girls' boarding school, which we first fumigated with formaldehyde and mopped with bleach.
I was exhausted, but once again could not sleep. There were too many impressions and questions racing through my head. We had no idea whether the epidemic was still spreading or how fast, but we clearly were approaching the heart of it: soon it would be staring us in the face. I wondered too what on earth happens at a Zairean funeral, and what could motivate a Flemish woman to spend her life in the middle of a faraway jungle, totally disconnected from her world, without the most basic infrastructure and communication. How could you run a 100-bed hospital without even one physician? How did people survive in these villages? How could I be most use-ful here?
...We heard of entire families who had been wiped out by the swift moving virus. In one case, a woman in Yambuku had died days after giving birth, swiftly followed by her newborn. Her thirteen-year-old daughter, who had traveled to Yambuku to take charge of the child, fell ill once she returned to her home village and died days later; followed by her uncle's wife, who had cared for her; then her uncle; and then another female relative who had come to care for him. This extremely virulent, interhuman transmission was frightening.
The mystery fever's epidemic curve was starting to take shape. The classical epidemio-logical curve is pretty simple; it plots the number of new cases of an infection against time. In the simplest type of outbreak the number of people infected rises gradually, then picks up pace, reaching a peak at the midpoint of the graph.
... night by night, as we jotted down data and sketched out a picture from our interviews and notes, it appeared that although people were still dying (and dying horribly), the peak num-ber of new infections around the Yambuku mission might be, at least provisionally, behind us.
This was a huge relief. But another conclusion also began to take shape, and it was a great deal more uncomfortable to deal with. Two elements linked almost every victim of the mystery epidemic. One factor was funerals: many of the dead had been present at the funeral of a sick person or had close contact with someone who had.
Yambuku Mission Hospital
The other factor was presence at the Yambuku Mission Hospital. Just about every early victim of the virus had attended the outpatient clinic a few days before falling ill. We developed near-certitude about the mode of transmission one evening, when Joel and I were drawing curves showing the number of cases by location, age, and gender.
...Sister Genoveva told us quite freely that the few glass syringes were reused for every patient; every morning, she told us, they were quickly (and far too summarily) boiled, like the obstetric instruments employed in the maternity room. Then all day long they were employed and re-employed; they were simply rinsed out with sterile water.
...they used unsterilized syringes that freely passed on infection. Thus, almost certainly, they had unwittingly killed large numbers of people. It looked as though the only obstacle to the epidemic had been the natural intelligence of the villagers, who saw that many of the sick came from the hospital, and thus fled it; who knew to set up at least some barriers to travel, thus creat-ing a semblance of quarantine.
The nuns were totally committed women. They were brave. They faced an incredibly dif-ficult environment and they dealt with it as best they could. They meant well. We had shared their table and their lives for what seemed like far longer than four days, and every evening, as they sipped their little tots of vermouth, they had told us about the villages of their childhoods.
Every evening the discussion had ended up circling around and around the same subject -- the epidemic. Who had fallen ill first, when it had happened and how.
NNAAMMIINNGG TTHHEE VVIIRRUUSS
Late one night we were drinking Karl's Kentucky bourbon -- it was one of those half gal-lon bottles with a handle -- discussing what our new virus should be named. Pierre argued for Yambuku virus, which had the advantage of simplicity; it was what most of us were already call-ing the disease.
But Joel reminded us that naming killer viruses after specific places can be very stigmatiz-ing; with Lassa virus, discovered in 1969 in a small Nigerian town of that name, it had caused no end of problems to the people from the locality. Karl Johnson liked to call his viruses after rivers: he felt that took some of the sting out of the geographical finger-pointing. It was what he had done when he'd discovered Machupo virus in Bolivia in 1959, and it was clear that night that he had every intention of doing the same in Zaire.
But we couldn't call our virus after the majestic Congo River: a Congo-Crim virus al-ready existed. Were there any other rivers near Yambuku? We charged en masse to a not-very-large map of Zaire that was pinned up in the Fométro corridor. At that scale, it looked as though the closest river to Yambuku was called Ebola--"Black River," in Lingala. It seemed suitably om-inous.
So, there's no connection between the hemorrhagic fever and the Ebola River. Indeed, the Ebola River isn't even the closest river to the Yambuku mission. But in our entirely fatigued state, that's what we ended up calling the virus: Ebola.
Since the first outbreaks in Sudan and Zaire in 1976, over the next four decades Ebola has been responsible for ~25 outbreaks across central Africa. The human and scientific story of each of these outbreaks is compelling but will only be summarized here.
MMAARRBBUURRGG 11996677
In 1967 outbreaks of hemorrhagic fever occurred simultaneously in Germany (Marburg and Frankfurt), and Yugoslavia (Belgrade) among laboratory workers having contact with tissues and blood from African green monkeys imported from Uganda.
My training at the London School on the nature of Ebola virus infections left a permanent imprint on my brain. Not just my brain, but the brains of my esteemed classmates also. Towards the end of the training period, around final exam time, our class was asked by someone? to state one of the most significant lessons we'd learned during our course of studies. I don't remember who asked the question, nor do I no why.
But I do remember that the class response as to the most valuable lesson learned in our course was [with due deference to Ebola]:
If your friend from central Africa is flying into town for a visit, and he has complained of a sore throat, DO NOT go to the airport to pick him up.
None of the previous outbreaks invaded large cities, travelled to other countries by air; the total number of deaths from Ebola cumulatively over four decades was around 1500, a number that the outbreak of 2014 on it's own, quickly exceeded.
During the previous decades, the nature of the virus, it's behavior, the best approach to containing it's outbreaks, all became common knowledge. The high risk of death for medical personnel who didn't use protective gear exactly as instructed, was great and well known. The principles of dealing with an Ebola outbreak were relatively simple, though in practice [like treating an Ebola patient] extremely time consuming and resource dependent.
The earliest detection [along with rapid diagnosis] of persons infected with Ebola was im-portant. Each victim had to be isolated in a secure facility. Caregivers had to be religious, fanati-cally meticulous in use of their personal protective gear. All contacts of the infected person had to be ascertained, tracked down and quarantined.
All practices which would exacerbate the spread of the epidemic [such as certain burial
practices] had to cease. Educating the populace about Ebola and preventative measures neces-sary, has been extremely important.
Below: a graphic depiction of previous Ebola outbreaks indicating their geographic lo-cation and relative size.
An excellent resource for reviewing the history of all Ebola outbreaks, which contains his-torical annotations and provides geographical locations and details of each outbreak, is the Google Earth KML listed below:
For some time after the 1976 outbreaks in Africa began, the culprit responsible for the deaths in Sudan and Zaire remained a mystery. Eventually, tissue samples from infected victims reached Dr. Frederick Murphy at the CDC in Atlanta. Dr. Murphy had an electron microscope and one memorable day became the first human ever to see this previously unknown killer's physical structure.
Below, a few segments from a recent interview of Dr. Murphy by Jeffery Delviscio.
A. That day remains very vivid in my memory. It raised the hair on the back of my neck, the first image. I was the only one left at the C.D.C. who had worked with the Marburg virus in 1967. And the two viruses look alike. I was pretty sure it was Marburg, which was bad enough, but by the end of the day, we knew it was different.
A. In 1967, Marburg virus appeared in Europe in several places that were processing monkey kidneys to make cell culture for things like the polio vaccine. The people started getting sick. Eventually seven people died. That was really the first high containment work we ever did at the C.D.C. We received the virus immediately from Germany and from Britain and went to work on it just to get the basics, so that the C.D.C. would be ready for whatever might happen.
It was another league of threat. This virus was incredibly lethal in monkeys. The patholo-gy is dramatic. The shape of the virus is dramatic. There were so different -- Ebola and Marburg -- from all the little round viruses that people would otherwise think about. It really got our atten-tion.
Above left: Marburg virus Right; Ebola virus. Electron microscopic images.
A. They are actual filaments, just a flexible rod, and according to how they lay down, the shape will look different. If you look across the electron microscopic field, you see them in all different forms. I think there is something in that shape that is emotional or it strikes something fundamental in the way we think -- not that all the other viruses are alike. The variety of shapes is quite amazing. But this was outside the frame of reference, it really just grabs you.
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Even though Ebola virus triggered it's first outbreaks in 1976, it was later determined that the first non-native survivor of an Ebola virus infection was infected in 1972. One day that year, an extremely ill patient presented at the clinic run by a medical missionary to Zaire, Dr. Thomas Cairns. The patient died shortly after he presented. His peculiar illness resulted in an autopsy which was done by Dr. Cairns. During the autopsy process the doctor inadvertently cut himself on the hand.
“Twelve days later I became acutely ill,” Cairns said. “I had a very high fever, intense aching, headache, vomiting, diarrhea, rash. My skin was peeling. I lost hearing in one ear for weeks. My hair turned white. We didn’t know what was happening to me.”
His symptom cluster didn't fit with any previously encountered disease. His illness did not comport with any illness known in the region, nor with any illness he was familiar with. “We thought it was going to kill me,” he said. “That was a real possibility.”
Eventually, he did recover, but it took many weeks before he returned to a semblance of his former physical status. Over the ensuing years of medical work in Zaire, Dr. Cairns put his near death experience behind him. Then one day in 1976, four years later, Ebola virus made it's first official appearance in the outbreaks in Sudan and Zaire.
In the post-outbreak serological investigations, epidemiologists collected blood samples from the indigenous population along with samples from about 50 expatriates working and living in the affected areas. In the process, Dr. Cairns's blood sample was obtained and the serology done. To everyone's surprise, the tests revealed Dr. Cairns had a significant titer of antibodies to the virus which was no known to be Ebola.
A high titer of antibodies to Ebola means that sometime in the not too distant past, Dr. Cairns had been infected by the Ebola virus. Obviously, had survived the infection. His peculiar, life-threatening illness four years earlier --- in retrospect --- was that infection. That illness, had walked and talked like a duck, and the discovery of his elevated Ebola antibody titres was the epidemiological Quack! Dr. Cairns the first known, non-African to survive infection by the Ebo-la virus.
There is a major qualitative factor that makes Ebola much more threatening than nearly any other contemporary threat. ISIS may do some pretty horrible things on video, but ISIS can't stop you from showing affection to other human beings. It's been remarked that Ebola's “cultural casualty” has been human contact.
We often curse terror groups that use children as human shields; Ebola similarly uses human decency against us by preying on our need for human contact and comfort. When Ebola is in the game, the good Samaritan becomes the dead Samaritan.
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Over the decades, a considerable amount of information about Ebola virus, it's structure, it's reproduction cycle, how enters and leaves cells it infects, the characteristics of the illness it causes in humans, are known. Fairly recently, the genome of the Ebola virus, the specific genetic sequence of it's RNA, has been deciphered. It codes for seven proteins and is a stretch of RNA just under 19,000 base pairs long.
Not too long ago the Ebola virus was categorized as a type of filovirus.
Filoviruses are enveloped, nonsegmented negative-stranded RNA viruses. "Filo" alludes
to the long stringy appearance of these viruses under electron microscopic examination. Filo-viruses cause a hemorrhagic, febrile illness. The mechanism by which the Ebola virus disrupts the functioning of a human body resembles that of HIV. It causes an immunodeficiency problem for the infected human.
Ebola viruses fall into the Order Mononegavirales, along with many other viruses. This Order contains a number of viral Families. Ebola virus belongs to the Family Filoviridae. The Family Filoviridae consists of the Genus Margugvirus and the Genus Ebolavirus.
Both Marburg and Ebola viruses are deadly for human beings and are classified as bi-osafety level 4 pathogens. The two species, both Marburg and Ebola virus, though similar in ap-pearance, are serologically, biochemically, and genetically distinct
The Genus Ebolavirus has five members, five Ebola virus subtypes. The deadliest subtype
is the Zaire Ebolavirus, which is the virus causing the epidemic in west Africa today..
As mentioned earlier, Marburg virus was first isolated during an outbreak in Europe in 1967 while the existence of the Ebola virus became known in 1976 [as the causative agent of two simultaneous outbreaks in southern Sudan and northern Zaire]. Although the main route of Ebola virus infection is known to be person-to-person transmission by intimate contact, the natural res-ervoir for filoviruses still remains a mystery. Fruit bats are strongly suspected of being the cul-prits, but that's based mostly on how ugly they are [my opinion].
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During those periods of one's life when you aren't actively infected by an Ebola virus, the structural elegance of the virus can be appreciated almost like it was a work of art. The virus is a beautiful object. Whether it could be considered a living creature, is probably the subject of many an argument. I don't believe it is, which makes it's existence and functioning highly myste-rious.
Ebola, like other viruses, doesn't particularly seek out human beings to infect. We are such easy conquests once infected, that the virus has a short period of exuberant growth, filling our bodies with uncountable numbers of copies. Then we die, and when we die, the Ebola virus dies with us. From an Ebola virus point of view, that's not an efficient way to make a living.
But, I really don't know what it is that an Ebola virus would consider making a living. However, if it's to find a body to reproduce in, a body that will tolerate your viral presence for long periods of time and let you achieve your virus goals without dying, then the bat is a better choice for a host than a human being. What the point of being a virus is, I've never heard a good explanation.
No matter what an Ebola virus aspires to in life, it is magnificently overbuilt, and overor-nate by an order of magnitude. Ebola virus diameters are consistently ~ 80 nm. While the length of the thready creature is usually at least 900 nm the 80 nm diameter threads can exceed 18,000 nm in length.
The virus has an outside and an inside. Inside the outside, a coiled [helical] nucleocapsid is found. This is basically the viral RNA with a protein wrapping that runs through the center of the virus. I don't know if the longer viral forms contain repeats of the basic genome, or it's local-ized to a certain region of the viral structure.
Closely apposed to the nucleocapsid is an envelope derived from the host cell plasma membrane. Then, like the bulbs on a Christmas tree, the external surface of the virus possesses a surface projection layer composed of viral glycoproteins. All these elements are exquisitely packaged in a structure that is, for all practical purposes, overbuilt.
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The virus's genes [in the schematic above] are arranged linearly on a single negative stranded RNA molecule that encodes seven structural protein. The structure, manufacture, and function of these proteins is known in some detail.
The proteins coded for are a nucleoprotein (NP), several structural proteins (VP) VP35, VP40, a glycoprotein (GP), the V's VP30, VP24 and finally a RNA-dependent RNA polymerase (L) The NP is the primary structural protein associated with the filovirus nucleocapsid. Since this RNA negative sense strand is read from left to right, NP forms early in the reproduction cycle.
Science journal published an drawing of an Ebola virus cutaway [above], revealing in beautiful detail the known structure of the virus. This work of art is worth a few minutes of close-up review.
Below, another schematic depiction of the Ebola virus. The relationships of the major vi-
ral components are clear: an outer envelope surrounding the coiled nucleocapsid within which contains the genetic material. The virus resembles a long filament or thread, hence it's categori-zation as a filovirus.
The filoviridae have lived in central Africa for millions of years. The Ebola virus and the Marburg virus, which are separate genera today, diverged from a common ancestor which lived around 18 million years ago. Undoubtedly, over the centuries, these viruses have been responsi-ble for repeated small deadly outbreaks, invisible to the greater world but devastating small iso-lated communities within central Africa's jungles.
The origin in nature today and the natural history of Marburg and Ebola viruses remains a total mystery. It seems that the viruses are zoonotic, transmitted to humans from ongoing life cy-cles in animals.
Approximately 8% of the human genome that consists of information inserted by various viruses over the past several millions of years. To be a human being is to carry the genetic inher-itance not only of our primate cousins, other furry mammalian friends, and even our far distant reptilian ancestry. To be a human being means also to carry the genomic legacy of viruses so dis-
tantly related in terms of phylogeny that they are usually not even considered living things at all.
The ancestors of today's filoviruses have been intimately involved in the lives of primates for the last 40 million years. Examination of the code that makes us 'uniquely' human, discloses the presence of many ancient coding sequences from the Filovirus genus, specifically the Ebola and Marburg viruses.
Over millions of years, making use of coincidence and opportunity, the genetic instruc-tions for making Ebola viruses have been slipped into our genetic code book. We carry this around with us, pass it on to our children. The recent discovery of Ebola virus genetic sequences embedded within the human genome was a huge surprise to me. This is like finding a trout in the milk -- an explanation is mandatory.
There must be some evolutionary benefits arising from this circumstance. Retaining viral sequences for over forty million years may convey some protection against infection by these viruses today. Believing that, however, takes a bit of imagination. Some scientists suggest the integrations of viral genetic sequences act as genomic vaccinations. Judging by what's happening in west Africa as I write, this form of vaccination is highly inefficient. But there's evidence that whatever the benefits, they are being experienced now, in real time.
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This Ebola epidemic is terrible no matter which of its parameters are used as descriptors. But we tend to easily forget that the world until very recently has been subjected to a number of much more destructive epidemics. Consider a couple of examples.
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Smallpox is a highly contagious viral disease that kills about one out of every three or four humans it infects. In the twentieth century smallpox killed over 300 million people. 300 million lives is three times more than all the lives lost in all the wars in that warlike century. Smallpox was the curse of mankind.
But then an astounding thing happened. In 1967, WHO launched a plan to eradicate smallpox. The global eradication of smallpox was certified by a commission of eminent scien-tists in December 1979 and subsequently endorsed by the World Health Assembly in 1980.
So, just one year after I graduated from medical school [1976] the last case of smallpox on this planet, occurred in Somalia. When that victim recovered, no other cases of smallpox oc-curred. After thousands of years of killing human beings, the human beings yanked it's chain. The eradication of smallpox is one of the greatest accomplishments of humankind. Unbelievable, astounding, ridding us of this prolific killer just a few years ago.
The smallpox virus still exists on earth, but only in confinement. The CDC and the Rus-sians each have a lab which retain specimens of the virus in high security conditions. Both the CDC specimens and the Russian specimens were scheduled for destruction, but have gained a reprieve. The CDC stache holds about 500 strains of the virus. CDC assures everyone the small-pox virus is highly contained in a freezer that is never opened.
In the striking image below, by photographer Kieran Kesner, an Ebola worker in Monro-via deals with the corpse of a woman who died of Ebola. Confidence in the eradication of small-pox except for two highly secured staches, is subject to doubt. In June 2014, several vials of smallpox were discovered in an unused storage room at the National Institutes of Health in Be-thesda, Md. The smallpox samples were found in a lab run by the Food and Drug Administra-tion. [Probably some more vials of smallpox in the Department of Transport]
The vials of smallpox, which apparently date to the 1950s, were "immediately secured" in a CDC containment lab, according to a CDC statement. NIH officials alerted the CDC about the smallpox July 1. A government aircraft took the smallpox vials to CDC's high--containment fa-cility in Atlanta on Monday, according to the CDC statement. Overnight genetic testing in a top--security lab confirmed that the vials did indeed contain smallpox.
In 1967, many countries still had smallpox. It was at this time that Dir. Bill Foege, a mis-sionary doctor working in Nigeria, developed a new evidence-based epidemiological strategy of search and containment. Although he was not the first to propose it, he provided convincing evi-dence of how successful it could be in field conditions. It involved searching for all cases of
smallpox--smallpox was always clinically apparent in an infected person--and isolating that per-son and vaccinating the person's contacts or potential contacts in a ring around where that person was living. The strategy was to search for cases of smallpox, or rumours of smallpox, from house to house, in markets, or public gatherings, and then to initiate containment activity by targeted vaccination.
In all countries that still had smallpox, intensified search was conducted using recognition
cards for children or adults who had the disease. Investigators recorded names and addresses, information on movements, isolated infected patients and conducted ring vaccination.
The last case of smallpox in the United States occurred in 1949. In October 1977, the last case of smallpox in nature occurred in Somalia. Ali Maow Maalin, a 23--year--old hospital cook in Merca, had never been successfully vaccinated. After his diagnosis, an intensive tracing and vaccination campaign led to 54,777 people being vaccinated in the next two weeks.
The last known case of smallpox any where, occurred in the United Kingdom in 1978 in a laboratory in Birmingham, where a medical historian and librarian working in G block became infected with smallpox, went home and infected her mother and father. Just 30 years ago, in 1980, smallpox was certified as eradicated from the globe.
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The second example of a recent deadly pandemic is the 1918 influenza A pandemic which claimed more than 20 million lives worldwide in less than a year. This pandemic ranks among the worst disasters in human history. In the United States alone, it is estimated that 1 in 4 people became ill during the pandemic and that 675,000 people died.
It occurred in two waves. First, a mild wave occurred simultaneously in the United States, Europe, and Asia in March–April 1918. Likely, genetic changes in that virus resulted in high pathogenicity in the second wave. The second wave occurred in September–November 1918 and affected one-quarter of the world's population; 500 million people were clinically affected during
smallpox--smallpox was always clinically apparent in an infected person--and isolating that per-son and vaccinating the person's contacts or potential contacts in a ring around where that person was living. The strategy was to search for cases of smallpox, or rumours of smallpox, from house to house, in markets, or public gatherings, and then to initiate containment activity by targeted vaccination.
In all countries that still had smallpox, intensified search was conducted using recognition
cards for children or adults who had the disease. Investigators recorded names and addresses, information on movements, isolated infected patients and conducted ring vaccination.
The last case of smallpox in the United States occurred in 1949. In October 1977, the last case of smallpox in nature occurred in Somalia. Ali Maow Maalin, a 23--year--old hospital cook in Merca, had never been successfully vaccinated. After his diagnosis, an intensive tracing and vaccination campaign led to 54,777 people being vaccinated in the next two weeks.
The last known case of smallpox any where, occurred in the United Kingdom in 1978 in a laboratory in Birmingham, where a medical historian and librarian working in G block became infected with smallpox, went home and infected her mother and father. Just 30 years ago, in 1980, smallpox was certified as eradicated from the globe.
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The second example of a recent deadly pandemic is the 1918 influenza A pandemic which claimed more than 20 million lives worldwide in less than a year. This pandemic ranks among the worst disasters in human history. In the United States alone, it is estimated that 1 in 4 people became ill during the pandemic and that 675,000 people died.
It occurred in two waves. First, a mild wave occurred simultaneously in the United States, Europe, and Asia in March–April 1918. Likely, genetic changes in that virus resulted in high pathogenicity in the second wave. The second wave occurred in September–November 1918 and affected one-quarter of the world's population; 500 million people were clinically affected during
the pandemic.
General Erich Ludendorff, the Imperial German Army Chief of Staff, concluded that it was the virus, not the fresh troops, that ended the World War. A remarkable feature of the 1918 pandemic was that deaths were highest among young adults in the 20–40 year age range.
The return of military personnel throughout the world coincided with the peak of the se-cond wave. In many cities, the disease was so severe that coffins were stacked in the streets, and the impact was so profound that it depressed the average life expectancy in the United States by more than 10 years. In spring 1919, a nasty but less lethal third wave occurred, and substantial mortality also recurred in 1920.
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The question of what exactly gave that virus it's remarkable killing power is being untan-gled. Tissue samples retrieved from victims of the 1918 epidemic have been retrieved and mo-lecular analysis undertaken. Thus far, study has shown that the 1918 virus was derived from avi-an influenza precursors and was most closely related to classical swine influenza virus.
By the time I left for west Africa, speculation as to the reasons for the alarmingly different nature of this Ebola epidemic, were the subject of discussion by many professionals as well as regular citizens. The panoply of suspect causes ranged from witches to weather.
However, early papers on the epidemic supported the idea that the virus involved was ba-sically the standard Ebola virus and that the aberrant nature of the epidemic was due to other fac-tors which obviously needed to be delineated and dealt with.
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The 2014 Ebola outbreak has already killed more humans that all previous Ebola out-breaks combined. A major scientific question is whether the culprit is the Ebola virus we already know, or if the virus has mutated into an even more deadly filovirus.
If the answer is that the Ebola virus of 2014 is the Ebola virus we know from previous outbreaks, then what other factors could be in play that turned this epidemic such a killer?
My trip to west Africa is motivated by the possibility, if still unknown factors of this na-ture do exist, they may be discoverable by a careful, openminded search. Expert studies have and will be done on this subject. One more review, even if by a single person, if done with an open mind and due diligence, had a small but real probability of revealing such factors.
By "openminded" I mean the scientific consideration of all/ any potential influences on the epidemic no matter how unrelated the connection may initially appear. [Elsewhere, this philoso-phy is compared to the discovery of the Bingo score in the Rothman Index.]. For example, if rainfall patterns in an outbreak's location were determined, would they disclose a correlation be-tween a season with an aberrantly high rainfall and a subsequent Ebola outbreak? It doesn't mat-ter [initially at least] why this correlation exists, but if it exists it has predictive value and could alert the world to take action at the earliest stages of an outbreak.
[Later, I came across papers in which this possibility was considered.] Consider one more example: Just before the world's first Ebola outbreak in Nzara, Sudan,
not far to the south of this region, Zaire and German scientists constructed a major rocket launch-ing facility essentially in the middle of the jungle. Even though the major intrusion of humans, machines, associated construction in the formerly remote area was some distance from Nzara, could these two events be causally related?
There's no evidence to link the rocket launch facility constructed at Shaba North in 1976 to the appearance of Ebola in Nzara, but the point of this example is that consideration of a broad range of nontraditional possibilities, is now mandatory. We need to understand the reasons for the anomalous nature of the current epidemic. Without that knowledge, how can we take appro-priate action to prevent a recurrence.
Data relevant to the question of whether the Ebola virus of 2014 is the same Ebola virus we've known for years, or an altered, game changing virus, appeared in Science journal on Sep-tember 12, 2014 in a paper describing the genomes of Ebola viruses obtained from infected Sier-ra Leonians in March and April 2014.
Above: the launch pad at Shaba North is located on the brink of a cliff. Zaire's space program failed to get a rocket into orbit, but did put some missiles into the villages in the valley below.
Determining the genetic identity of the Ebola virus causing the current epidemic became the focus for urgent scientific research once the existence of this epidemic became known. Sev-eral early papers, published by PLOS and online, indicated that the Ebola virus running rampant in west Africa between March and May 2014, was genetically consistent with a previously known Ebola virus, that it was not a significantly mutated version.
Under the circumstances at the time, this finding implied that the growing epidemic began with a single introduction of the Ebola virus into the human population. The findings weren't consistent with the idea that Ebola viruses from multiple sources were repeatedly being seeded into the human population.
Definitive evidence that answered this question finally appeared in an excellent paper published by Science, on September 12, 2014. In May, the Ebola virus outbreak had remained confined to Guinea. Then, in Sierra Leone next door, the first patient to present with Ebola virus infection appeared in the form of a young woman who had suffered a miscarriage.
She recovered and in the course of events, the genome of the Ebola virus found in her blood was sequenced. In addition, between May and mid-June 2014, the genomes of Ebola vi-ruses recovered from the blood of 77 other Sierra Leoneon Ebola victims were also sequenced.
The results of this sequencing were reported in this Science paper. The conclusion reached by the researchers is that the virus ravaging west Africa is the "normal" Ebola virus and thus the savagely, different nature of this outbreak [compared to previous outbreaks] is due to factors ex-trinsic to the virus itself. This finding is of major importance for many reasons, including those I had taken to heart prior to coming to Liberia.
The data in the paper also suggests how this Ebola virus arrived in Guinea. The possibility that Ebola had been circulating under the table in these west African countries, until it finally infected a human being, is not supported by the evidence. The data in this paper suggest that the 2014 epidemic west Africa is caused by the previously known central African Ebola virus which spread to the region via an as yet unknown animal vector, within the past decade. Subsequent spread of EVD is due to human to human transmission, not by repeated injections of Ebola virus from this animal reservoir.
Above, the remains of Shaba North today.
A copy of the first page of the Science paper is reproduced below.
First page of remarkable "Science" paper, September 13, 2014
Tragically, five of the medical personnel who contributed to this multi-authored paper, died of Ebola virus infection before the paper was published. This is a heavy price to pay. One of the five was Dr. Sheik Humarr Khan, acknowledged as a national hero in Sierra Leone.
Above: The quality of the data reported from the field, initially poor and confusing,
gradually improved through the late summer and fall. This is a nice graphic depiction of the situation in Liberia in August, 2014.
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This new evidence supported the suspicions of scientists earlier, that despite the aberrant nature of this epidemic, the dynamics were basically those of a standard Ebola outbreak. "Stop-ping the outbreak at the source in Africa will take many months. Three core interventions have stopped every previous outbreak and can stop this one as well: exhaustive case and contact find-ing, effective response to patients and the community, and preventive interventions. Identifying infected persons quickly requires accessible diagnostic and treatment facilities."
By October fairly solid evidence about the dynamics of the epidemic, was available, to al-low scientists to conclude:
"Although the current epidemic of EVD in West Africa is unprecedented in scale, the clinical course of infection and the transmissibility of the virus are similar to those in previous EVD outbreaks. The incubation period, duration of illness, case fatality rate, and R0 are all within the ranges reported for previous EVD epidemics. Our estimates of R0 are similar to other recent estimates for this West Africa epidemic.
The combination of signs and symptoms recorded between symptom onset and clinical presentation is also similar to that in other reports. We infer that the present epidemic is excep-tionally large, not principally because of the biologic characteristics of the virus, but rather be-cause of the attributes of the affected populations and because control efforts have been insuffi-cient to halt the spread of infection."
The R0 parameter referred to above can be calculated for a given epidemic once some sol-id data is obtained. Using data between March and July from the current epidemic produced an R0 which fluctuated around 1. This indicated that "modest further intervention efforts at that point could have achieved control."
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Although the current epidemic of EVD in West Africa is unprecedented in scale, the clini-cal course of infection and the transmissibility of the virus are similar to those in previous EVD outbreaks. The incubation period, duration of illness, case fatality rate, and R0 are all within the ranges reported for previous EVD epidemics.
Past Ebola outbreaks have been snuffed out, often within a few months. How, then, did this one spin so far out of control? It is partly a consequence of modernization in Africa, and perhaps a warning that future outbreaks, which are inevitable, will pose tougher challenges.
Unlike most previous outbreaks, which occurred in remote, localized spots, this one began in a border region where roads have been improved and people travel a lot. In this case, the dis-ease was on the move before health officials even knew it had struck.
This part of west Africa had never seen Ebola before. Health workers did not recognize it and had neither the training nor the equipment to avoid infecting themselves or other patients. Hospitals in the region often lack running water and gloves, and can be fertile ground for epi-demics. Public health experts acknowledge that the initial response was significantly delayed, both locally and internationally, and was inadequate.
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Health experts have grown increasingly confident in recent years that they can control Ebola But those successes hinged on huge education campaigns to teach people about the disease and persuade them to go to treatment centers. Much work also went into getting people to change funeral practices that involve touching corpses, which are highly infectious.
Above: a colonial era map depicting a process which laid the foundation of the Africa of today. Africa at the time [not depicted in the map] consisted of many different. Afri-
ca's native populations communicated in a multitude of languages.
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The current epidemiological outlook is bleak. Forward projections suggest that unless control measures -- including improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from
international partners -- improve quickly, these three countries will soon be reporting thousands of cases and deaths each week.
Experimental therapeutics and vaccines offer promise for the future but are unlikely to be available in the quantities needed to make a substantial difference in control efforts for many months, even if they are proved to be safe and effective.
Furthermore, careful assessment of the most effective means of utilizing such interven-tions (e.g., vaccination or treatment of contacts versus health care workers) will be required while stocks remain limited.
For the medium term, at least, we must therefore face the possibility that EVD will be-come endemic among the human population of West Africa, a prospect that has never previously been contemplated. The risk of continued epidemic expansion and the prospect of endemic EVD in West Africa call for the most forceful implementation of present control measures and for the rapid development and deployment of new drugs and vaccines.
Certain characteristics of the affected indigenous populations may have fueled the rapid
geographic dissemination of this outbreak. The populations of Guinea, Liberia, and Sierra Leone are highly interconnected, with much cross-border traffic occurring at the epicenter and with rel-atively easy connections by road between rural towns and villages and between those and the densely populated national capitals.
The large intermixing population has facilitated the spread of infection, but a large epi-demic was not inevitable. In Nigeria, the number of cases has so far been limited, despite the in-troduction of infection into the large cities of Lagos (approximately 20 million people) and Port Harcourt (>1 million people). The critical determinant of epidemic size appears to be the speed of implementation of rigorous control measures.
Previous experience with EVD outbreaks, though they have been limited in size and geo-graphic spread, suggests that transmission can be interrupted, and case incidence reduced, within 2 to 3 weeks after the introduction of control measures.
Above: the richness of Africa exemplified by the multitude of languages spoken.
Poverty is considered the single most important precondition for an outbreak of such an unbridled nature. Liberia, Sierra Leone, and Guinea are respectively ranked 174, 177, and 178 out of 187 countries on the United Nations Development Program Human Development Index.
Annual incomes are ~ $300. The region has ~ 1 physician for every 65000 residents. [US has about 1 physician for every 450 residents.]
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There were small riots in this Monrovia slum with about 80,000 residents. One writer who visited this section of Monrovia wrote:
"the most revelatory portions of our trip to Liberia came from meeting the major warlords of the nation's civil wars. There's a tradition in Liberian militias of taking on extravagant noms de guerre. Hence, our subjects were named General Bin Laden, General Rambo and General Butt Naked. The latter, in particular, was one of the most notorious Liberian warlords. He claims to have personally killed 20,000 people including babies, and to have sometimes canni-balized his victims."
The devastating effects of the recent civil wars in Liberia and Sierra Leone clearly pre-pared the 'ground' for this epidemic. These wars are associated with large numbers of refugees moving across national borders. The destruction of the infrastructure, especial the health care infrastructure facilitates what it now occurring. Then there is a long history of bad government, corruption, waste of resources, all leading to a countrywide infrastructure that barely functions under normal conditions. Guinea has a history of decades of inefficient and corrupt government that have left the country in a state of stalled or even retrograde development.
Previous Ebola outbreaks have been exacerbated due to the traditional burial practices in these nations. These practices include the bathing of corpses by hand prior to burial. This factor also impacted previous outbreaks, to varying degrees. In west Africa, traditional burial practices do have a facilitating effect on the spread of the virus due to the deep meaning associated with burial practices.
For example, in Sierra Leone Ebola cases are found in villages in Mende-speaking areas.
In Mende burial practices mourners touch the corpse to express sympathy or say farewell. Corpses are often moved between villages, obviously increasing the risk of transmission to both local and distant communities.
Three Corners, where Guinea, Sierra Leone and Liberia meet.
A woman on marriage relocates to her husband's village. If she dies of Ebola, she will be buried in her home village. Roughly 50% of married women in a Mende village were born in an-other village. Marriage in this culture is a continuum with a "completed" marriage at one end of the spectrum. The bride to be goes with the future husband on his agreement to provide gifts and services for the woman's parents, and on partial fulfillment of his promises. But the marriage re-mains "incomplete" until all of his promises have been fulfilled. This can take years.
A woman from another village, whose marriage falls into the unfulfilled category [the ma-jority of marriages], will be buried in her birth village. Upon the death of a woman who original-ly came from another village, who had an incomplete marriage, her husband will need to obtain permission from her parents to bury her. This requires him to travel to his wife's home village and after first fulfilling his marriage promises, seek this permission. Upon receiving this permis-sion, his wife's corpse will be taken to her home village and buried. Even if the wife is buried in her husband's community, the potentially Ebola infected husband is still obliged to travel to her parent's community after burial to fulfill his marriage promises.
I am not writing from first hand knowledge here. These statements they are taken from an anthropological study and I assume are credible. Thus, from the point of view of an Ebola virus --if a wife dies from Ebola, she leaves behind a highly contagious corpse. Her husband likely will be aymptomatic but infected with Ebola also. Customs require the travel of an infected person and the conveyance of an infectious corpse, to an unsuspecting, often distant commuity. Clearly, even prior to the actual burial ceremony, this process will result in rapid geographic spread of the virus.
More than 80 percent of all marriages in which the female partner comes from another vil-lage were incomplete in this study. These customs clearly are deeply imbedded in the communi-ties and will not be modified for trivial considerations. In an outbreak situation, outside medical advice to such villagers asking them to change their customs, must of necessity -- in order to be effective -- be crystal clear and present the villagers with a strong and understandable rationale.
LLAARRGGEE PPOOPPUULLAATTIIOONN CCEENNTTEERRSS
The spread of EVD into larger population centers is unique to this outbreak.
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Widely believed superstitions and unfounded beliefs as to the etiology of the epidemic, al-so work against efforts to positively change a population's behavior, to make it less risky, in the face of this epidemic.
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For instance, many 'educated' residents of these nations don't believe Ebola virus infection is real.[This puzzled me for a time shortly after I arrived in Monrovia. Large billboard like signs
proclaimed "Ebola is Real!" I didn't know many people didn't believe Ebola was real.]
Widely held conspiracy theories, really off the wall theories which are truly believed by many, work against those trying to halt the epidemic. There have been attacks on health care teams in the villages. 8 members of one team spraying chlorine in a Guinea village were mur-dered because the villagers were told, or believed, that they were actually spraying Ebola virus into their village.
The Ebola related deaths of many health care workers also has many ramifications, all of which hinder the detection and isolation, of the victims, and hinder contact tracing. Often Ebola infected persons hide in their homes, trying to avoid hospitals and evade authorities. All these elements combined create a formidable obstacle to the efficient anti-Ebola work.
The multitude of problems that arise in regions afflicted with wars, rebellions and persis-tent strife, affect all the countries involved in this outbreak.
1. Infrastructure destruction
2. Refugees and population movements 3. Chronic bad government, corruption
An article by Kai Kupferschmidt expanded on the theme of poor government and corrup-tion as factors predisposing to such a hazardous epidemic as now existed in west Africa.
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After Oyewale Tomori finished his talk on Ebola here at the International Meeting on Emerging Diseases and Surveillance there was stunned silence. Tomori, the president of the Ni-gerian Academy of Science, used his plenary to deliver a scathing critique of how African coun-tries have handled the threat of Ebola and how corruption is hampering efforts to improve health. Aid money often simply disappears, Tomori charged, "and we are left underdeveloped, totally and completely unprepared to tackle emerging pathogens."
A: We were totally unprepared. After the first cases occurred in West Africa, it took al-most 3 months for WHO to know. When the first patient came to Sierra Leone and died, his son brought him back to Guinea and as far as Sierra Leone was concerned, it was Guinea's problem. People abandoned their duty, they denied the problem, and when it became a big problem they became incapable of handling it.
This is not the first time Ebola has appeared in Africa. There have been more than 20 out-breaks since 1976. Not one of them has been declared a global problem. Of course, circumstanc-es are different this time. But if we had been prepared, if we had learned from the past, we wouldn't be where we are today.
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A: Yes, I am, because I know Africa has the capacity and the capability to solve most of her problems, but Africa will not enable her human resources to perform effectively and effi-ciently. African leaders have little or no respect for their experts and would rather act on advice from external sources. In the end, they become the experts on Africa's problems, not the Afri-cans. This is why I am angry with Africa.
We have seen so many Ebola cases before, in the DRC, in Sudan, in Gabon. ... Ebola is Africa's problem. We should have put something in place. I remember in 1995, when we had the Kikwit epidemic, at the end we sat down at a table and discussed what we should do. There was a laboratory in Kinshasa built by the French; it was almost completed, but then abandoned.
We had raised almost $2 million at the time. And we said: "Why not take a bit of that money and complete this lab and maintain it? Then at least when we have issues like this we can do quick testing." But nothing happened. The carcass is still there. Each time I pass the place, I think: "What a waste."
A: We were not prepared, we were lucky. Patrick Sawyer was already sick when he ar-rived, so he went straight to the hospital. And because our doctors were on strike, the public hos-pitals were not open, so he went to a private hospital. If Sawyer had gone into a public hospital, we would have had a bigger problem.
But within 2 to 3 days of Sawyer coming in, we knew it was Ebola from laboratory tests done in two of our university laboratories, and then action was taken. I praise Nigeria for that. We had this emergency center from the polio network and we brought people in and traced al-most 1000 contacts. This was not passive tracing; people went to contacts' homes on a daily ba-sis.
A: People say African countries are poor. But it's not poverty. It's misuse of what we have. As we are talking, with all the crises that are going on, the presidents of our countries are still traveling in the best of conditions. Some will come to New York in their private jets, alt-hough their national airlines collapsed years ago; in addition, they will bring along a long retinue of private, personal, and public assistants, all lodged in the best hotels.
I am not saying the president should not be treated well, but these are issues we need to look at. Take my country: We do not have a national airline, but the number of private jets we have is more than all the airlines in Africa have together.
It's a matter of priorities. I do not believe there is an African country that cannot buy gloves for its staff. Personal protective equipment may be very costly, they may need assistance on that. But let us participate. As long as we are wringing hands waiting for the next glove to come, we will never be ready. There are certain things we can do now, with the resources we have.
A: GAVI [a public-private partnership that funds vaccines for low-income countries] just sanctioned Nigeria after a critical audit report. GAVI gave us money to do certain things, and we could not account for $2 million or $3 million of it. GAVI insisted that Nigeria must pay back that money, and the government agreed.
But our government should not just agree to pay back the money, the government should find out who misused the money, get the money back from those persons and not from public coffers. And those people should be brought before the courts to answer for the deaths of the children who did not receive the vaccines that the GAVI money would have provided.
A: To give you one example, there are 600 Nigerian health care workers who want to go to Liberia. But the process of getting them there has been going on for months. If the African team, the African Union, the Economic Community of West African States, and the West African Health Organisation all get their acts together, there are more than enough people in Africa -- health care workers from Gabon, DRC, Uganda, Sudan -- who have experience with this.
But we must find the funds to provide insurance for all national and international health workers who are currently working or have volunteered to work in the Ebola-affected areas of Africa. Bear in mind, in Africa we do not have a welfare system. I am the welfare system for my family, my brothers, my uncle. So when I go to an Ebola region, I am thinking of the 23 other people that depend on me. If there is no insurance, I will stay home.
A: I am angry at them, too. They should take the lead of Ebola control efforts --not Ge-neva, not Washington, not New York. The [Centers for Disease Control and Prevention] can help, [Doctors Without Borders] can assist, but it is WHO's African region that should coordi-nate and take the lead. It's all meetings and reports. Nothing on the ground.
A: These elections are just horse-trading. If the person who wants to get elected requires the vote from Nigeria for example, because it is the ministers of health who do the voting, I might say: "OK, I will vote for you, but I need one directorship from my country."
If he accepts that, he has to accept whoever I bring, regardless of how competent the per-son is. That is what has messed up Africa. WHO's regional office has never been able to solve Africa's problems because of this system of electing its leaders. You want to find the most com-petent person. Vote on that basis. Not because I visited you and I promised you this or that.
A: I wish I could say with confidence that in 10 years' time we will not be where we are now with Ebola. But the countries have totally lost control of what is going on. If you go to Sier-ra Leone or Liberia today, there must be at least 10 international groups there. At the end of this epidemic, everybody will pack their bags and leave.
The African countries will be left not really knowing what has happened to them. Like someone hit them smack in the face, totally disoriented. There will be millions of scandals about how money was misspent and so on. We will focus on those and move on. Ten years from now, people will have forgotten that there was Ebola and we will be back to where we started.
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My brief study of the history of Liberia let me understand one author's comment that:
"In Liberia the graves are always fresh."
Ebola’s current ravages, awful as they are, pale in relative terms to what the first pioneers faced. Malaria and yellow fever hung over Monrovia and the other settlements like a fog. Moans and groans and the stench of diarrhea emanated from the so-called receptacles, the barracks set up for new arrivals; people wandered the grassy streets in fevered dazes. One historian, calling early Liberia a “charnel house,” estimated it suffered “the highest rate of mortality ever reliably recorded.” Of the nearly 3,000 settlers arriving in the 1830s, more than a third died.
Wars between native and settler punctuated Liberia’s first century. The native Africans of the coast felt they had been forced at gunpoint to give up Mesurado and they did not like the fact that the fiercely abolitionist settlers kept interfering in the lucrative business of smuggling slaves.
Above: The formerly Grand Masonic Temple in Monrovia in July 2014. Many promi-
nent buildings in Monrovia, damaged in the previous war, populate the city today serv-ing as s blackened, shotup mementos of the most recent ot the periodic violent spasms
which are the bane of Liberia.
In 1847, Liberia became the world’s second black republic, after Haiti. Liberia’s found-ing fathers created a republic but kept it for themselves, much like their former masters had done back in 1776. The omission would haunt the republic for the rest of its days.
After many decades of relative anonymity, during and after WW2, prosperity came knocking on Liberia's door, for the first time. Playing out a version of the gay 90s, for several decades the new middle classes and sprinkling of upper classes celebrated debutante balls at the Ducor Hotel, the upper classes spending the summer in Europe, while the real business of gov-ernment was conducted behind the closed doors of the Grand Masonic Temple in Monrovia.
These circumstances soon deteriorated however. Liberia suffered from corruption, bad government, and rebellions, fights, wars and turmoil. In the last decade prior to the peace treaty in 2003, the country was savaged by the depradations of well armed men, teenagers and children. This author states that the civil was was so brutal it beggars the imagination. Teenagers forced to kill their parents to prove allegiance to one warlord or another. The killing of elders on whim.
"On my visits to Liberia in the late 1990s, I interviewed nearly 100 people; I rarely met anyone who had not personally witnessed a murder, often of a loved one."
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A review of this region's overstocked repository of violent rebellions, civil strife, and wars, is depressing and shocking. The echos of those recent events are alive and reverberate in the country today. Along with most of the world I was shocked by media reports from Liberia in 1980. The Liberian government had been overthrown by a soldier named Samuel Doe.
Above: a graphic depiction of the regional wars, rebellions and strife across Africa.
One of his first acts, which was shown to the world, was to bind 13 members of the over-
thrown government to large wooden posts set in the beach near Government House. A bloody, disgusting mass shooting conducted before the world's cameras, then dispatched these men. They had been tortured and abused prior to their execution. After the execution the brutal treatment of Liberias citizens continued, both in public and out of sight of the world.
He's considered a war criminal. But, as seems to not infrequently be the case, he did have a relationship with the US and one time was invited to America where he met President Reagan at the White House. The President greeted him as "Chairman Moe." Doe's depredations continued until he was in turn overthrown in an ugly reversal of fortune.
Reports of the beach executions, the rampant killings and outrages in Liberia, made this reader actually feel sick. I remember it well.
Thirteen leaders of Liberia's toppled ruling elite were executed by firing squad here today before hundreds of shouting, cheering soldiers and civilians. The 13 men, who had formed the top echelon of the oligarchy that had held largely unchallenged power since Liberia's founding 133 years ago by freed American slaves, died tied to posts with their backs to the Atlantic shore on which their 19th century forebears first set foot.
Those executed included Frank Tolbert, brother of assassinated president William Tolbert, who was slain in the April 12 coup of noncommissioned Army officers, and former foreign min-ister C. Cecil Dennis. Trussed to a hastily placed steel pole, Frank Tolbert, once the powerful president of the Senate, began to sink slowly to the ground, unable to stand on his quaking legs as he awaited the shot. Saliva drooled from his mouth as he slumped against a cord tied tightly around his bare chest.
Soldiers laughed and tormented the men. Former foreign minister Dennis stared stoically into the crowd as one of the soldiers stomped on his feet. Dennis closed his eyes and mouthed a prayer, and another soldier shouted, "You lie! You don't know God!"
Their deaths came following a coup that ended a belated effort to reform an archaic sys-tem of government that had for too long held on to century-old concepts that only the propertied should rule and have access to power. That system was swept away today as Liberia was thrust violently into 20th century Africa. The announcement of the planned executions came matter-of-factly this afternoon following a 10-minute press conference at the executive mansion by Libe-ria's military head of state.
Master Sgt. Samuel K. Doe. Doe led the coup that toppled the Tolbert government and killed 27 other officials of the government and the ruling True Whig Party. As the press confer-ence broke up, the new minister of information, Gabriel Nimely said, "Gentlemen of the press, you are all invited to the executions." Asked who would be executed, Nimely stonily replied, "enemies of the people."
The coup originated among lower-ranking officers of Liberia's indigenous Africans, the majority of the country's 1.6 million population. A selected few of Liberia's "safe" natives, deri-sively called "country people" up until the coup, were allowed entry into the minority ruling Americo-Liberian or "settler" class of 45,000 people, descendants of the freed American slaves.
Of the 14 people tried so far by a special five-man military tribunal, only one, former in-formation minister Johnny McClain, has escaped execution. McClain, 38, is an indigenous Libe-rian who rose from reporter to the top position in the Information Ministry under Tolbert. In an interview in February, McClain said he had suffered abuse and humiliation from Americo-Liberians when growing up, and had cleaned dormitory toilets to pay for his education at the University of Liberia.
"The Americo-Liberian class is not as distinct today as it once was," McClain said in Feb-ruary. "There are more of the 'country people' who have class status today but there are still problems between the rich and poor."
McClain contended that Tolbert, who for nine years had led a country that was known for its stability on a continent where military coups are common, had gradually opened the political system for the participation of larger numbers of indigenous Liberians.
But McClain was still in an Army stockade, with 80 untried prisoners as the gunfire -- fol-lowed by cheers of approval -- erupted at the seaside execution site. A huge mass of Monrovia's poor waited in gleeful anticipation as reporters followed Sgt. Doe's convoy to the execution site at 2:15 p.m.
The crowd stared at four 20-foot poles silhouetted against the ocean whitecaps. Then, at 2:30 p.m., two large mechanical hole cutters and five additional poles were brought to the site as foreign television cameras filmed the quick erection of the additional posts. At 3:30, a bus carry-ing the 13 condemned men drove up and the soldiers cheered. Nine of the 13 were tied to the available posts while the other four were left on the bus to watch. A passing soldier shouted at the reporters, "You know, we got to stop all the corruption in the country."
Deputy Brigade Commander (formerly corporal) Harrison T. Penue, identified by Doe as the man who killed Tolbert, strutted up to the reporters and said, "I am executing 13 men today because I don't like corruption."
Former finance minister James T. Phillips, dismissed from the government recently after
thousands of dollars in receipts disappeared following an Organization of African Unity summit conference here last summer, made barely audible pleadings of innocence as he and others were tied to stakes. Then 13 soldiers carrying M1 rifles marched up to the unblindfolded men and ar-rayed themselves, one rifleman to each, a few feet in front of them. There was a brief tussle as one of the spectator soldiers tried to take the position of the soldier in front of Dennis.
Soldiers mugged for cameras alongside the condemned men. Then the order was given to fire. The soldier assigned to Dennis wounded him once and missed twice. The spectator soldier opened up with his Uzi into Dennis' face, showering bone and brains. The soldiers cheered and mugged for more pictures.
P. Clarence Parker Jr., once of the four prisoners on the bus, smiled and waved weakly to a reporter who had interviewed him in February. Parker had been one of the harshest critics of the corruption that riddled the Tolbert government, but he had also been treasurer of the ruling True Whig Party and a millionaire paint manufacturer.
Parker, with the three others, walked quickly to a pole, faced the firing squad and smiled slightly before a single shot cut him down. As the cheering civilians surged forward, the specta-tor soldiers sprayed all 13 bodies with automatic rifle fire, replacing their ammunition clips as they emptied one after another.
At his press conference before the executions, Doe said, "The revolution which brought down the Tolbert government was motivated by the sufferings of the Liberia people throughout our country. Things were fixed in such a way that only a very few people enjoyed everything."
"The judiciary was a mockery in many instances because cases were determined by how much money one could offer," Doe said.
"The armed forces have taken over the government to recover from their long years of suf-fering and when things begin to get on the right track, we, the men and women in arms, will re-turn to the barracks where we belong," he pledged.
Born 1931, Montserrado County, Mr. Charles "Cecil" Dennis was a well known and well respected Liberian political figure who was American educated and who served as Secretary of State/Minister of Foreign Affairs under President William Tolbert from 1973 until the coup d'état by Samuel Doe on April 12, 1980. Along with other members of Tolbert's Cabinet, he was promptly put on trial and executed later by firing squad ten days after the coup.
In 1980, Samuel Doe was in charge of a beachfront security patrol near the Executive Mansion. Doe and his army friends grew up in meager conditions, mostly living in huts, with nothing much to eat and attending school when they could. In the army, life was not much better, just more wooden shacks with corrugated zinc rooftops. There was no electricity, no plumbing and no running water.
One day, after having a few beers, Doe and his soldiers playfully talked about overthrow-ing the government. It started out as a joke, but they eventually decided that it would be quite easy. Despite what people say about conspiracies, the idea and cause of the coup was just that spontaneous and simple. That is why it shocked so many people, including the American gov-ernment. Nobody even knew who Doe was in Liberia. He was not well known at all.
After the coup and contrary to popular belief, Cecil Dennis never attempted to take refuge at the U.S. Embassy in Monrovia. Dennis had just arrived back in Liberia a few days before from an overseas trip. He, along with his brother and their families, were hiding at a friend's house try-ing to decide what to do. Dennis later made a few phone calls to various embassies including the U.S. asking about the situation but later decided to turn himself in to Doe's People's Redemption Council (PRC).
Later that afternoon, Max Dennis, a cousin drove him to the Barclay Training Center ar-my barracks as instructed by the radio broadcasts. Although Dennis was received in orderly fash-ion, once there, he was arrested and locked up to await charges of corruption and a slew of other crimes placed on him by the newly formed military junta. U.S. officials stated that a few of the other "wanted" Liberian officials like Justice Minister, Joseph Chesson, did contact them asking about the situation, but none requested help or asylum.
This would turn out to be an enormous mistake. As far as the U.S. was concerned, this coup was coincidental in that it was an election year. In addition, Jimmy Carter and his admin-istration were planning the rescue attempt for the American hostages in Iran, which failed on
April 25, 1980, three days after the executions. The Americans were not going to intervene here in Liberia, at least not on a military level. The Americans did plead for leniency and due process, something which Doe ignored.
It is said that A.B. Tolbert, who was William Tolbert's son, was allowed refuge at the French Embassy, but Doe's men ignored diplomatic immunity and demanded his transfer to PRC headquarters. Tourists, foreign visitors and other citizens all suffered too, as soldiers all around Liberia raped, robbed and pillaged for several days following the coup. This was class AND eth-nic warfare at its finest, but there was also a bit of drunkenness and chaos thrown in for good measure.
After over 130 years, this was simply a case of the "haves versus the have nots". People with no economic background stealing from others is basically all it was and this coup would be the beginning of the end for Liberia. She would not recover for nearly 30 years.
Burleigh Holder, Minister of Defense, who survived the ordeal described their treatment just after the coup while in custody and awaiting trial or execution:
"Within a few days of my imprisonment, sixteen of us, prisoners, were called out to dig holes in the grounds of the prison. I was told to dig a hole ten by ten feet...we were handed a shovel each... rifles began firing all around me so close to my body that sand was thrown up onto [me]...
By this time a crowd of at least four to five thousand people had gathered in the open field around, all derisively gazing at the spectacle...I was ordered to strip buck naked while dig-ging...a soldier advanced to the partial dugout and emptied a potty of human feces into it, and he ordered me to eat it...Each mouthful was mixed with sand, and I was forced to swallow it."
While detained and crowded together in their cells, the doomed ministers and officials seemed resigned to their fate. They had been mistreated and starved for ten days. In the few vid-eos that exist during their confinement, they all look like soulless and ghostly images, forever regretting why they did not attempt to make a run for it. Worse than that, they had no news of what was happening to their families, their wives and their children.
Recent Truth and Reconciliation Hearings have produced a witness from the prison who had run errands for the men, such as picking up money for bribes for guards for better food and treatment, to delivering and retrieving notes to and from their families. This witness claims that one "note" from Frank Tolbert was so long as to take up an entire roll of toilet paper. The witness had to flush it down the toilet though, due to fear of being caught by another guard who may have seen the exchange.
Frank Senkpenni was an army colonel and the judge who presided over the kangaroo court trials. He is seen in the famous video telling the defendants to "keep it short" with their an-swers. Most defendants tried to briefly discuss their contributions to the Liberian people, as a clerk typed away on a typewriter taking their testimony and minutes.
The court also asked each man how many houses, lots and businesses they owned. Again, the "haves versus the have nots" in full effect, the indigenous Liberians versus the Americo-Liberian. It was pure class struggle at its finest.
There is a strange photo showing Frank Tolbert, older brother of William Tolbert, laugh-ing and enjoying a Fanta soda pop with soldiers either before or after the courtroom proceedings. Frank must have been liked for his personality. Who knows what was going on there, but he would be dead within days.
Ten days later after the coup, and following a puppet show trial headed by a military pan-el of the PRC, Cecil Dennis and twelve other government officials were taken to a beach, a block south of the Barclay army barracks west of the Executive Mansion, and murdered in front of screaming crowds of jubilant indigenous Liberian citizens. It was a nightmarish scenario.
Cecil Dennis faced death very bravely, staring at his killers while awaiting his fate. When he mouthed a prayer before being shot, a soldier loudly shouted "You lie! You don't know God!" After the order to fire was given, his drunken executioner may have winged him but the other bullets missed altogether, splashing into the Atlantic Ocean behind him.
He was the only person still alive after the first barrage of gunfire. Two more soldiers fi-nally approached and sprayed Cecil with an Uzi and pistol at point blank range, hitting him in the face, body and head, until he was deceased. Each man was later hit with 50 or 60 extra bullets by the drunken soldiers.
Oddly enough, after the execution, Doe called for Cecil Dennis to be brought to the Exec-utive Mansion because Doe had questions about certain foreign affairs. Cecil Dennis was already dead. Executed. In the days prior, Doe was shown the execution list but never fully read the list of those to be executed. Either Doe was only semi-literate or obviously did not bother to read everything put in front of him.
The court recommended death for only three men: Chief Justice, James A.A. Pierre; Speaker of the House, Richard Henries; and Frank Tolbert, President of the rubber stamp Liberi-an Senate. However, there was space on the page showing the remaining men below as getting prison terms or other sentences. Regardless of whether he read the list or not, Doe may have simply said to kill them all to avoid them starting a counter-coup.
It could also have been a misunderstanding, especially since not enough poles were in-stalled on the beach to begin with and more poles had to be brought in later, further delaying the executions that day. This makes the entire story even that more bizarre. Thus, that is west Africa for you...and as always, simply bizarre.
...There were several elderly men being killed that day, and one of them was Frank Tol-bert. Frank was President William Tolbert's older brother. Mr. Tolbert was the smallest in stature and as his shaky legs gave out, he slouched as the shots rang out and killed him. While still tied to the pole, his small frame was nearly sitting on the ground as he lay dying with drool running out of his mouth. A foreign journalist stated that Richard Henries and Frank Tolbert had already died of a heart attack or had both passed out somehow before being shot.
Quite possibly the real reason all of the officials were killed was because Samuel Doe and the PRC decided that with their powerful friends, connections and resources, these men could easily stage a foreign backed counter-coup. They may have been right. The lack of sympathy shown by the Liberian people during the executions helped fuel the brutality of the coming Civil War.
...I have studied world politics for a long time, and this event is one of the most bizarre and surreal things that I have ever seen on video or even read about. It seems that the world has forgotten about it, or maybe they just know how politics and coups can be in west Africa. It is a real shame...
ABOVE: image by Larry Price, showing Sir Cecil Dennis immediately prior to his exe-
cution.The photographer was awarded a Pulitzer Prise for this image.
Hard to believe, but media reports documented Doe's capture in Monrovia, about a decade later, by a militia leader Prince Y. Johnson. Johnson took Doe to his military base. There Doe
was tortured. His fingers and toes were amputated and he was killed. After his naked body lay exposed on a Monrovian street, his body was cut into pieces, cooked and eaten.
Years of reports even more sickening than this, cast a dark shadow over Liberia's past. That shadow is visible today. The sense a visitor often shivers to is of the thiness of civilization's veneer and the fragility of the apparent order that is present now.
MEDIA REPORTS FROM INSIDE THE EPIDEMIC
The vignettes that follow are taken from some of the many excellent news reports on the epidemic. They are arranged in approximately chronological order. Their cumulative effect is to present for those of us who weren't there, the human face of the epidemic. Personally, I value these reports because they describe memorable events and the people involved in the epidemic, documenting the essentials of the epidemic from long before I paid attention to the tragedy. I'm grateful to those who were on the scene and recording the events from the beginning. I'm im-pressed by the excellence of many of these reports.
Some information presented below only became available months after the occurrence of the events they describe. Thus, for example, the scientific description, the media depiction, of the index case in Guinea. This little boy in Guekodou, came to public attention only after investiga-tions had time, many months, to make this determination after the epidemic began. Most of the writings that struck me, presented the human face of the epidemic.
As mentioned, I believe the reporting on this epidemic is exceptional. Reports from the BBC, the NYT, NPR, Reuters, and so on, convey to the extent possible, the story of humanity under siege, of people striving to cope with extremes, of everyday life; for me, the media records in toto represent a valuable archive of historical importance.
I suspect that the extensive, skilled reporting on this epidemic is part of the phenomenon I discussed in "Tsunami Journal." As technology has drawn the people of the world together, the suffering of our fellow man [as reported in the media] involves us with much greater immediacy than it would have decades ago. To make this point even more arcane, let me just say it's "Old Masters" stuff.
NNOOTTEE::
A number of entries below were acquired from French language news reports out of Guinea and Sierra Leone. I employed Google Translate to render them into English. The results are sometimes ambiguous but for the most part, the gist of these reports can be discerned.
Below, a series of extracts from news accounts follow, reports on the "progress" of the Ebola epidemic, arranged roughly in chronological order. These reports gave me some idea of the circumstances in west Africa during the early months of the epidemic. In the beginning, Guinea is the focus of attention, but I've included reports from a broader geographic region and extended the time coverage into December 2014 [after I'd returned from Liberia].
Next then, a report from AfricaGuinee, translated from French, written in March 2014 when the source of the increasing number of human deaths was unknown.
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A new disease which we do not know the name was reported in the prefecture of Macenta located 800 KM from Conakry, killing 8 people and infected many others, learned Afri-caguinee.com.
Considered contagious disease is manifested by anal and nasal bleeding. According to a state nurse at the district hospital Macenta, reached by telephone by our editorial staff, the dis-ease broke out there two weeks in the urban district of Macenta and some surrounding villages.
"Indeed, this is an extremely serious case because it is a very heavy bleeding. The disease is characterized by bleeding from the nose. We we do not know the disease there. I myself got a case; it is a nasal and anal bleeding."
"It's not actually confirmed because it may be more because in remote villages people do not point directly to the hospital," said the nurse Sadio Barry. To believe our interlocutor, a team was set up to put patients in quarantine to prevent contam-‐ination. According to our information this disease look like Lassa fever, a contagious disease, a native of Liberia. She rages at a time in the neighboring countries of Guinea and had caused several deaths.
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On March 18 Guinean health officials announced the outbreak of a mysterious hemor-rhagic fever "which strikes like lightning." 35 cases were reported, and at least 23 people had died. In mid-March, Guinea's Ministry of Health asked Doctors Without Borders for help in Guéckédou. At first, the group's experts suspected Lassa fever, a viral disease endemic in West Africa. But this illness was worse than Lassa.
Guinean health officials have registered 49 cases of infection in three southeastern towns and the capital Conakry since the outbreak was first reported on Feb. 9. While the exact type of the fever, which is characterized by bleeding, has yet to be identified, a senior official in Guinea said on Friday preliminary tests had narrowed down the possibilities to Ebola or Marburg Hem-orrhagic Fever. WHO officials, however, suspect Lassa Fever may be behind the outbreak, cases of which have now also been reported in a border region in Sierra Leone, according to minutes of a March 18 teleconference seen by Reuters.
Sierra Leone's Chief Medical Officer Dr. Brima Kargbo said authorities were investigating the case of a 14--year--old boy who died in the town of Buedu in the eastern Kailahun District. The boy had travelled to Guinea to attend the funeral of one of the outbreak's earlier victims. Kargbo said a medical team had been sent to Buedu to test those who came into contact with the boy before his death.
International medical charity Medecins Sans Frontieres (MSF) announced on Saturday it was reinforcing its team in Guinea. It is also flying in 33 tonnes of medicines and equipment and is setting up isolation units in three towns.
"These structures are essential to prevent the spread of the disease, which is highly conta-gious," Dr. Esther Sterk, MSF's Tropical Medicine Adviser, said in a statement. "Specialised staff are providing care to patients showing signs of infection"
After the isolation units were set up, and subsequent tests of those infected, confirmed it was Ebola virus. The next mandatory required to stop this outbreak was to identify all infected patients and isolate them. Just as essential is the necessity of tracing all contacts of all infected persons. This is a labor intensive, fairly monumental task.
All contacts had to then be monitored for 21 days in order to detect those who would come down with an Ebola infection during that incubation period. Following these steps with diligence offers the only hope of containing the epidemic, and eventually stopping it.
Even if infected persons and their contacts cooperate with this protocol, the task can be mind boggling. The contact list for one victim may contain over a hundred names. And as men-tioned earlier, quite often these folks are not interested in working with health care officials, to the extent that they actively work to subvert the process.
"They go to the field to work their crops," said Monia Sayah, a nurse sent in by Doctors Without Borders. "Some have phones, but the networks don't always work. Some will say, 'I'm fine; you don't have to come,' but we really have to see them and take their temperature. But if someone wants to lie and take Tylenol, they won't have a temperature."
Dr. Simon Mardel, a British emergency physician, works out of Donka Hospital in Guin-ea's capital. He's worked on seven previous hemorrhagic fever outbreaks. He quickly realized the current outbreak was the worst he had seen.
A man arrived at Donka late one night, panting and with abdominal pain. He had been treated at two private clinics previously, given intravenous fluids and sent home. The staff did not suspect Ebola because he had no fever. But fever can diminish at the end stage of the disease. The man died two hours after arriving. Tests later showed he was positive for Ebola. A large numbers of health care workers and patients had been exposed to the disease.
Treatment facilities in the entire region, as a rule, are scarcely adequate and in fact are like high risk areas for transmitted Ebola infection from new patients to the medical staff. The treat-ment room at Donka was poorly lit and had no sink. There were few buckets of chlorine solution, and the staff found it impossible to clean their hands between patients.
Gloves, in short supply at the hospitals, were selling for 50 cents a pair on the open mar-ket, a huge sum for people who often live on less than a dollar a day. At homes where families cared for patients, even plastic buckets to hold water and bleach for washing hands and disinfect-ing linens were lacking.
Unsuspected cases of Ebola, appearing at the hospital without standard infection control measures, worsens the spread of Ebola in a "vicious circle," Dr. Mardel said.
"The Ebola virus has been identified as the cause of an outbreak of hemorrhagic fever now believed to have killed nearly 60 people in southern Guinea, government officials say. Scores of cases have been recorded since the outbreak began early last month."
From this date for months onwards, the warnings by MSF, seemed to fall on deaf ears. In-ternational inaction, without signs of leadership from WHO, characterize the next 6 months global response to a growing humanitarian tragedy.
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The outbreak of the deadly Ebola virus in the West African country of Guinea is "very worrisome," according to a virus expert. UNICEF said at least 59 of the 80 people infected with the disease had died and the virus appeared to have spread to the capital, Conakry. The deadly hemorrhaging fever is spread by close contact with infected people or objects.
"Ebola has no successful treatment... so the main way to prevent the spread of this out-break is going into isolation."
An outbreak of the Ebola virus - which has already killed 59 people in Guinea - has reached the capital Conakry, the UN's children agency has warned. Unicef said the haemorrhagic fever had spread quickly from southern Guinea, hundreds of kilometres away. Scores of cases have been recorded since the outbreak began last month. There is no known cure or vaccine.
It is spread by close personal contact with people who are infected and kills between 25% and 90% of victims. Symptoms include internal and external bleeding, diarrhoea and vomiting.
"At least 59 out of 80 who contracted Ebola across the West African country have died so far," a Unicef statement quoted by the AFP news agency.
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"Over the past few days, the deadly hemorrhagic fever has quickly spread from the com-munities of Macenta, Gueckedou, and Kissidougou to the capital Conakry."
Conakry is a sprawling port city, where up to two million people currently live. The UNICEF statement also said that at least three victims of the virus were children. Outbreaks of Ebola occur primarily in remote villages in Central and West Africa, near tropical rainforests, the World Health Organization says.
Analysts suggest it has never been recorded in Guinea before. Recent years have seen out-breaks in Uganda and Democratic Republic of Congo.
"We got the first results from Lyon yesterday which informed us of the presence of the Ebola virus as the cause of this outbreak," Guinean health ministry official Sakoba Keita told AFP on Saturday. "We are overwhelmed in the field, we are fighting against this epidemic with all the means we have at our disposal with the help of our partners but it is difficult."
Medecins sans Frontieres said on Saturday it would strengthen its team in Guinea and fly some 33 tonnes of drugs and isolation equipment in from Belgium and France. Dir. Armand Sprecher, an emergency physician and epidemiologist working with MSF in Guinea, told the BBC that doctors had to identify all patients with the disease and monitor anyone they had been in contact with during their illness.
The latest outbreak could be brought under control if people acted quickly, he said. "Based on our history with these sorts of outbreaks it will happen. Ideally, sooner rather than later," said Dr. Sprecher. "The more quickly we can contain this the fewer cases we'll have, then the smaller the scale of the epidemic. That's the idea of going in as strong as we can early on."
Bats, a local delicacy, appeared to be the "main agents" for the Ebola outbreak in the south, Rene Lamah said. Sixty-two people have now been killed by the virus in Guinea, with suspected cases reported in neighbouring Liberia and Sierra Leone. Ebola is spread by close con-tact. There is no known cure or vaccine.
It kills between 25% and 90% of victims, depending on the strain of the virus, according to the World Health Organization "This is the first time such a national health threat has come to our borders"
It is the first time Ebola has struck Guinea, with recent outbreaks thousands of miles away, in Uganda and the Democratic Republic of Congo. Mr. Lamah announced the ban on the sale and consumption of bats during a tour of Forest Region, the epicentre of the epidemic, re-ports the BBC's Alhassan Sillah from the capital, Conakry.
People who eat the animals often boil them into a sort of spicy pepper soup, our corre-spondent says. The soup is sold in village stores where people gather to drink alcohol. Other ways of preparing the bats to eat include drying them over a fire.
Aid agencies and the government are taking medical supplies to the affected areas in Guinea. Certain species of bat found in West and Central Africa are thought to be the natural res-ervoir of Ebola, although they do not show any symptoms.
Health officials reported one more death on Tuesday, bringing the number of people killed by Ebola to 62, our correspondent adds. The charity Medecins Sans Frontieres has set up two quarantine sites in southern Guinea to try to contain the outbreak, the Associated Press news agency reports. Health authorities are receiving help from the WHO while messages are being broadcast on national television to reassure people.
Mr. Kargbo said one suspected case involved a 14-year-old boy buried in a Sierra Leone-an village after he apparently died across the border in Guinea two weeks ago. The other patient was still alive in the northern border district of Kambia, he added.
Five people are reported to have died in Liberia after crossing from southern Guinea for treatment, Liberia's Health Minister Walter Gwenigale told journalists on Monday. However, it is not clear whether they had Ebola. Outbreaks of Ebola occur primarily in remote villages in Central and West Africa, near tropical rainforests, the World Health Organization says.
The first two cases of Ebola have been confirmed in Liberia, after spreading from neigh-bouring Guinea, where the deadly virus has killed 78 people. The two Liberian cases are sisters, one of whom had recently returned from Guinea, officials say.
As concern grows over the outbreak, Senegal has closed its normally busy border with Guinea. Ebola is spread by close contact and kills between 25% and 90% of its victims. Senega-lese singer Youssou Ndour cancelled Saturday's concert in Guinea's capital Conakry because of the outbreak.
Although he had already travelled to Conakry, he told the BBC it would not be a good idea to bring hundreds or thousands of people together in an enclosed area. The outbreak began in Guinea's remote south-eastern Forest Region but last week spread to the capital, a sprawling city of two million.
ABOVE green box overlies locale in Guinea were the first victims in this Ebola epidem-
ic lived.
Senegal's Health Minister Awa Marie Coll-Seck said the government decided to close its border with Guinea after confirmation the virus had reached Conakry.
"When it used to be only in the south of Guinea, we didn't do anything special. But now that it's reached Conakry, we believe it's safer to close our borders," she said.
"We have also closed all weekly markets, known as luma, in the south. And we're having some discussions with religious leaders regarding big religious events."
There have also been suspected cases of Ebola in neighbouring Sierra Leone but these have not been confirmed. The outbreak is believed to have spread to humans from fruit bats, which are a delicacy in parts of south-eastern Guinea.
The government has now banned the sale and consumption of the bats. It has also urged people to ensure they regularly wash their hands with soap to prevent the virus from spreading.
On March 31, Doctors Without Borders described the current Ebola epidemic as "unprec-edented," and warned that the disease was erupting in so many locations that fighting it would be enormously difficult.
An angry crowd attacked a treatment centre in Guinea on Friday where staff from Medecins Sans Frontieres (MSF) were working to contain an outbreak of the deadly Ebola virus, forcing it to shut down, a spokesman for the medical charity said.
"We have evacuated all our staff and closed the treatment centre," Sam Taylor told Reu-ters, adding that the attackers in Macenta had accused MSF of bringing the disease to the south-
eastern town.
"We have the full support of the local leaders and we're working with the authorities to try and resolve this problem as quickly as possible so we can start treating people again," he said, declining to give further details of the incident.
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EVD has taken a heavy toll among health care workers in Guinea, Liberia, and Sierra Le-one. By September 14, a total of 318 cases, including 151 deaths, had been reported among health care workers.
From the start of the outbreak [now identified as December 2013] to 20 April 2014, 242 suspected cases in Guinea and Liberia had resulted in a total of 147 deaths. As of 20 April, 112 cases from Guinea have had genome sequences at least partially obtained, all of which are EBOV, and 69 deaths have been confirmed as EBOV positive, giving a confirmed case fatality rate of 62%.
The initial source of the outbreak appears to be the village of Meliandou in Gueckedou Prefecture, and the index case a 2-year-old child who died on 6 December 2013. From Meli-andou, EVD spread to five other locations in Gueckedou by the beginning of March 2014.
Gueckedou remains the main location of the outbreak with 122 suspected cases as of 20 April 2014. EVD appears to have been transmitted to Macenta by early February 2014 and then to Kissidougou by late February 2014. The first death in the capital city of Conakry was a busi-nessman who had travelled from Dabola in central Guinea. He became ill on 17 March 2014 and died the following day. He is suspected to have contracted EVD in Dabola through contact with a visitor from Gueckedou who also subsequently died from suspected EVD.
The dead businessman's body was taken from Conakry to Watagala, his village of origin. His four siblings who lived in Conakry, and who travelled with the body, and four other mourn-ers at his funeral have all tested positive for EBOV. Since then, the total number of suspected cases presenting in the capital has risen to 53.
The indirect impact of the outbreak on the Guinean economy has been extensive, with the transport, tourism and entertainment sectors badly affected as people avoid crowded situations. Fewer miners have reported for work, which may eventually have global implications, given that Guinea has one-half of the world's supply of bauxite, as well as significant iron, diamond and gold deposits.
The neighbouring republics of Sierra Leone, Mali and Liberia have also reported suspect-ed cases. Those from Sierra Leone have tested positive for Lassa fever, and EVD is not currently believed to have entered that country.
In Liberia, EVD appeared in the northern town of Foya, close to the Guinean border and only 24 km from the outbreak's main focus in Gueckedou. A woman arriving from Guinea transmitted the disease to her sister in Foya, who then travelled to the Liberian capital Monrovia, and then on to visit her husband in Firestone Rubber Plantation Camp, north-east of the city, be-fore dying on 2 April 2014.
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Conakry Guinean authorities continue to take action in the fight against Ebola hemorrhag-ic fever! The day after the summit held in Conakry, which brought together several heads of state of the West African sub-region, the Guinean authorities continue to adopt strategies against the virus that has already killed hundreds of people.
Logistics commission set up in the wake of the announcement of the Ebola outbreak in Guinea has deployed large resources in areas affected by the virus. Large batches of kits to pre-vent and fight against the virus were sent this week in several localities.
"We have several lots predisposed to the fight against Ebola disease. To date, all prefec-tural health directorates were supplied with chlorine solutions, gang protection and other pro-tection kits " testified Dr. Moussa Konaté.
This measure of pre-positioning initiated by the logistics commission would certainly fight effectively against the spread of the virus, especially in the cities of the interior often face a
lack of drugs. The commission has also set up a management system of all donations from part-ners. This software allows you to have all the information about an item, ie, the donor, the amount and even the profit structure.
After a meeting held last week in Conakry, the Heads of State of the Mano River Union decided among other things, take steps to stop the spread of Ebola. The leaders of these four countries also agreed to take important and special measures inter-country level to focus on bor-der regions with more than 70% of the epidemic.
"These areas will be isolated by the police and the army. Populations living in these areas are isolated, will be supported hardware. Health services in these areas will be strengthened to ensure treatment, testing and monitoring effectively contacts," stated the communiqué that sanc-tioned the meeting in Conakry.
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In addition to acting to stop this outbreak, we should put systems in place to prevent an-other one. Earlier this year, the United States joined partner governments, the World Health Or-ganization, and other multilateral organizations and nongovernmental actors to launch the Global Health Security Agenda which aims to better protect all people from health threats.
How the Ebola Treatment Centre at Donka? Guinea, like three countries in the West Af-rican sub-region is burning with a serious outbreak of viral haemorrhagic fever, Ebola. In nine months, she made more than 2,000 deaths in this region of Africa. Before using the international community (which is slow in coming) arrives, the affected countries are attempting hobbled to deal with the epidemic, with rudimentary means edge. Exclusive report in an Ebola treatment center in Conakry ...
The Guinea, which is part of the epidemic in January, is a small country in West Africa, located on the edge of the Atlantic Ocean. It has a 245,857 square kilometers and a population of less than 12 million. This 56-year-old state known since the beginning of 2014, one of the worst nightmares of his medical history. A highly contagious and deadly virus ravaging almost every-thing in its path, leaving only misery and desolation filed its venom in Guinea.
''It's a disease that has never known the country,'' says Dr. Barry Moumie, head doctor of the infectious diseases, which also runs the home care of the sick in the Ebola treatment center in the countries.
The health system in this country is one of the most deliquescent of the sub-region. It is in these circumstances that the Ebola virus is going to bare all the flaws of the country's health sys-tem. Less than 3% of the national budget allocated to the health sector.
''You have to be blind not to see that our health care system is sick,'' said the Guinean President Alpha Conde recently in the States-General of Health in Guinea. This statement by the highest authority of the country reveals many realities.
To date, the country has two Ebola treatment centers. One in Conakry and the other Guéckedou in the south of the country, the epicenter of the epidemic. ''We have two large treat-ment centers in the country.There is one Guéckédou and Conakry. There is also the transit cen-ters,'' explained the head of the host service Sick in Ebola treatment center.
Ebola treatment center of Conakry is inside the CHU Donka (the largest hospital in the country, who lives in incessant rhythm of electrical power cuts and water). It is housed in a large space next to the general administration of the hospital.
At first glance, the visitor is struck first by the fence, made of plastic mesh in orange. A first warning sign indicating that it is forbidden for anyone to take that foreign security cor-don.Inside, several tents are installed. The Médecins Sans Frontières logo is visible everywhere. A revealing elements that it is this humanitarian NGO which runs the center.
In September, two men dressed in dung [khaki?] are seated. They control each entry. One is responsible for raising the identity of people entering a big notebook, as the second drive is concerned that the rules of hygiene. Each visitor is subject to a strict exercise. A bucket filled with chlorinated water is flanked on a stool almost at the threshold of the door. A few meters, another is placed. It serves as garbage.
We must wash hands, disinfect shoes before entering the center. Each person who enters
or leaves is subject to this chore. This is the case of a Médecins Sans Frontières (MSF) who ar-rived aboard a Land-Cruiser in our presence. "Hello! How are you this morning? And family.'' After the usual greetings, everyone submits to the rite (hand washing, disinfecting shoes ...) be-fore disappearing inside the center.
Inside, everything looks tidy. Each category (confirmed cases, suspected cases, visitors, people contacts ...) to a tent that is exclusively and specially reserved for him. There for visitors, confirmed cases, suspected cases and people contact.
''In the center, we have well known compartments. There are so-called low-risk area and the high risk area. In the high-risk zone is defined in two parts. There is where we keep the sus-pect and confirmed cases where one keeps,'' said Dr. Moumie.
Here, patients are received from sorting. ''As soon as the patients come, he explains, sort-ing, we can make sense of things. If the patient meets the definition Ebola cases, we keep it, we treat", tells the chief doctor of the infectious diseases.
The day we arrived, 25 patients were followed at the center. Among them, 14 cases were confirmed, 11 are suspect. Three teams of eight agents take turns every day in patient monitor-ing. The treatments are done by team of at least two agents. But with such a deadly contagious virus that, it must be a highly impressive safety equipment to approach patients.
No part of the body does indeed stay outside. The whole body must be covered tightly. This protective clothing is called combination. When in this combination, you can lose up to 1 liter of water per hour; so that there is a scorching heat. This is why we can not stay there long.
Ebola is certainly a highly dangerous disease. But beyond its danger, and his killing spree, there only to fight, it takes a lot of resources. Apart boots and glasses, each combination should be incinerated after use. ''About 80 combinations are used per day," says an official of the MSF center. And no object must leave the center.
To strengthen their team, MSF is also responsible for the training of people who are cured of Ebola to assist in the care of patients. To date, fifteen was in training, will we were informed there.
The latest statistics of the epidemic in Guinea, provided by the Ministry of Health as of September 18 have reported 974 cases including 630 deaths.
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What are the latest statistics "macabre" of the epidemic of the viral hemorrhagic fever Ebola in Guinea? The virus that emerged in Guinea in early 2014 killed more than 1,500 people in the country, learned Africaguinee.com.
According to the head of the communications unit of Ebola in response committee in Guinea, Fode Sylla Tass. speaking this Friday, November 14, 2014, during a press conference in Conakry, the epidemic has killed so far, 1659 people . 69 agents infected health care including 43 who died , among the medical profession.
''From March to 14 November 2014, that damned virus killed 1,659 Guinean ... 69 agents who are health line first war against that damned virus were infected. Among them 43 have died ,'' said Fode Sylla Tass.
These figures show a clear increase in cases of deaths in the country. An increase of more macabre 600, are we remark. Because according to the latest statistics provided as of November 8, 2014, the government had provided the figure of 1079 deaths.
Tass Fode Sylla, condemns the fact that some families still continue to hide the sick. "The epidemic in Guinea today is that of reluctance and denial," he condemns.
The World Health Organization (WHO) on Thursday proposed eight treatments and two experimental vaccines against Ebola to develop faster, but that will not be available for general use by the end of 2014.
The African Union has announced a second emergency meeting Monday to strategize across the continent hit by the epidemic that can not be contained. However, none of the eight treatments and two experimental vaccines offer "has been clinically proven" according to the working paper published Thursday by the WHO for the 200 experts convened in Geneva to take
stock of the means to fight against Ebola.
Also, "so that exceptional measures are now in place to accelerate the pace of clinical trials, new treatments and vaccines will not be available for widespread use before the end of 2014," warned the UN organization.
"Until then, only small amounts of up to a few doses / treatments will be available," she said, noting that the development and clinical evaluation of these treatments take "up to 10 years normal circumstances."
The current outbreak of Ebola virus that continues to expand in West Africa is unprece-dented. Now there is no licensed vaccine against the disease, and there is no specific treatment. On August 8, the WHO declared the outbreak Ebola was "a public health emergency of global reach."
Early August, a committee of experts convened by WHO had given the green light to ex-perimental treatment, in the particular circumstances of the outbreak. Since serum stocks ZMapp, a promising treatment against Ebola virus tested for the first time in late July on humans but dif-ficult to produce in large quantities, have been exhausted.
According to the document released Thursday by the WHO, less than ten doses of ZMapp - part of 8 treatments listed Thursday by the WHO - have been used. WHO hopes that the ongo-ing efforts to increase production let get "a few hundred doses" end of 2014 ." In terms of the two candidate vaccines, WHO estimates that "thousands of doses should be available from the end of 2014 for clinical trials and compassionate use".
"In Sierra Leone, we have reached the end of our resources. If we let the country (acting) alone, we will still for some time" to end the epidemic, told AFP a representative of the Ministry of Health of this country, Samuel Kargbo, Geneva.
In its latest tally released Wednesday, WHO reported 1,841 deaths in 3665 case for the three West African countries most affected (Guinea, Liberia, Sierra Leone). On Wednesday, the director general of the WHO, Margaret Chan, however, had put the figure at 1,900 killed in front of the press, without going into the details of the balance sheets.
Liberia has recorded the highest number of cases (1698) and death (871). Nigeria is af-fected to a lesser extent (seven deaths) and a first case occurred in Senegal, one of a Guinean who had crossed the border.
The sporting events are increasingly disrupted. Saturday, spectators Nigeria Congo, quali-fier CAN-2015, Calabar (south-east), will be subject to Ebola testing, announced Thursday an official of the Nigerian state of Cross River. More than 20,000 people are threatened by the cur-rent Ebola epidemic according to WHO who thinks being able to terminate it before the best six to nine months.
"The situation is quite alarming. In countries where the epidemic began, we have seen that health systems (...) have not been able to really deal with this epidemic. The response must be much more careful," said the director of the Senegalese Institute for Health and Development (Ised) Anta Tal-Dia, present at the WHO meeting in Geneva.
French Secretary of State for Development and Francophonie Annick Girardin will visit on 11 and 12 September in Dakar from 13 to 14 in Conakry "to mark the commitment of France in the fight" against Ebola.
On the other hand, the contaminated American doctor, Rick Sacra, 51, who worked for the SIM charity to ELWA Hospital in Monrovia, left Thursday for the United States.
WHO is alarmed Thursday risk of rapid development of the Ebola outbreak in Port Har-court, large oil city in southern Nigeria, where two people died and another case was confirmed. According to WHO, about sixty persons under surveillance and are considered high risk in Port Harcourt. More than 200 people in total are followed.
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Conakry Vice President of the Union of Democratic Forces of Guinea this week launched an invitation to the Head of State of Guinea. Dir. Fode Oussou Fofana asked the head of the Guinean executive to make every effort to reopen the border between Guinea and other countries such as Senegal, learned Africaguinee.com.
For several months, the borders between Guinea and several countries in the sub-region are closed because of the outbreak of Ebola hemorrhagic fever. The African Union has adopted a
resolution on September 8 asking the states to open their borders with countries affected by Ebo-la.
For the president of the parliamentary group of the Liberal Democrats, we need the per-sonal involvement of President Alpha Condé for the resolution of the AU is a reality.
''We need the president Alpha Conde itself implies that the African Union call a special session of heads of state. Any decision that would result from this meeting will be more likely to be applied by States," estimated Oussou Dir. Fode Fofana.
They are very numerous, the Guinean students who were unable to join the Senegal be-cause of the border closure. Since the young student who had Conakry was declared Ebola virus carrier, Guinean seem to live a certain stigma to the country of Macky Sall.
It has also reacted following numerous complaints from compatriots of President Alpha Condé living on its territory, saying: "I strongly condemn any behavior to ostracize a community This is not because the cases detected in our city. of this country that all Guineans should be considered as potential carriers of the virus. I therefore appeal to respect their neighbors,"Mr Sall said in an interview with the newspaper the Express.
In an interview he gave to our editorial from the Ethiopian capital, the head of the Guine-an diplomacy welcomed the decision of the African Union calling on States to reopen the bor-ders with the countries affected by the Ebola virus.
''During the discussion, we talked about the stigma especially because we know that this stigma countries that are plagued with Ebola, we know that it exists. The decision of the African Union affects all forms of restrictions on travel and others. They were asked to stop. I think this is a very good decision'' declared the State Minister Francois Lounceny Fall.
President Barack Obama on Tuesday urged the US Congress to allocate an emergency fund of some six billion dollars to fight the Ebola outbreak in West Africa and manage risk in the United States.
"We can defeat Ebola without additional funding," he began, during a visit to the premises of the US Institutes of Health (NIH) in Bethesda, in the suburbs of Washington. "If we want oth-er countries continue to mobilize, we must continue to lead the way," said he added, noting that some 3,000 Americans, civilian and military, were now deployed on the ground in East Africa West, primarily in Liberia, the country most affected.
While acknowledging that the subject had hitherto broad consensus between Republicans and Democrats, he warned against the temptation to mix the financing of the fight against Ebola in the bitter budget discussions. Republicans in the House of Representatives had not yet pre-sented Tuesday bill to fund the federal government beyond the 11th.
"It is not a matter of policy. It is a matter of common sense. Let's do it! ", Launched Obama. Calling on members of Congress to vote, before going on holiday, "Dec. 12, he found that the vote of the emergency fund he had proposed in early November would be" a nice birth-day present for Americans and for the world. "
According to Jennifer Hing, spokeswoman for the Commission for finance laws in the House of Representatives, "no decision has been taken at this stage."
"The Finance Act should be debated next week," she said. Senate Democrats, budget ne-gotiator confided optimism for "total", while stressing that negotiations were continuing with the House.
"We need to eradicate this disease, it is not a virus that we can manage a few cases here and there," insisted the US president. "We can not lower our guard, if only for a moment."
Obama stressed that funding was needed in particular to accelerate testing promising treatment or any vaccine, including those developed by the NIH.
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In Guinea, 2696 children who have lost one or both parents of Ebola suites were identi-fied in 18 of the 23 prefectures targeted by the Ministry of Social Welfare with support from UNICEF and support Technical NGO Children's World (MDE).
In this context, 1300 children involved in Kissidougou, Guéckédou and Macenta received
individual kits from MDE. The families of the children (375 in total) for their part benefited from psychosocial support. 47 children also received clothing in Kourémalé (prefecture of Siguiri), representing all of the orphans in the district.
This activity of the NGO Enfance du Globe is part of its support to the prefectures of Sig-uiri, Yomou, Kouroussa Kérouané, Lola and Beyla, in the areas of protection and psychosocial support to children. 479 orphans are involved in total in these prefectures.
In the districts covered by these two NGOs, affected 780 children participated in psycho-social support sessions in which fun and educational activities were organized. Since October 2014, UNICEF has signed four MOUs with national and international NGOs to strengthen the government's response to Ebola for child protection and psychosocial support.
These are World of Children, Childhood Globe, ChildFund and Plan International, cov-ering a total of 20 prefectures. These agreements are designed to assist children in affected pre-fectures with special attention to children orphaned as a result of the epidemic.
Official figures on the situation of the Ebola epidemic in Guinea have reported new cases zero this week, while 111 patients including 77 confirmed cases are still in different treatment centers.
This is the Guéckedou processing center which features the most sick, 37 cases of which 27 are confirmed. Confirmed cases come from the prefectures of Macenta Kérouané N'Zérékoré Faranah, Siguiri, Kankan Beyla, Lola and Kissidougou.
The Guéckedou treatment center is closely followed by that of the capital Conakry, 36 cases with 26 confirmed. Then come the centers Macenta (22 cases including 15 confirmed) N'Zérékoré (7 cases and 2 confirmed) Kérouané (5 confirmed cases) and Siguiri (4, 2 con-firmed).
Four previously affected by the epidemic prefectures have not notified of new cases for 42 days, which made them "quiet homes." By cons, having notified new cases during the past 21 days, 17 of the 33 prefectures of the country remain "active homes." Only 9 Country prefectures have not been affected since the outbreak of the epidemic. These are the five prefectures of Labe region and prefecture of Mandiana, Gaoual, Koundara and Fria.
By publishing these figures Saturday, the coordinator of the anti-Ebola fight called to overcome the reluctance that continues to manifest itself in 17 localities of the country. He wel-comed the deployment of members of the government over the whole territory to support aware-ness.
Guéckédou Prefecture, where officially triggered the outbreak of the Ebola virus disease, now becomes a home "almost extinct" where for several days no new cases of contamination is registered according to the National Coordinator MSF in Guinea.
Met this Saturday in Conakry, Marc Poncin, MSF coordinator bluntly: "On Guéckédou, it is very clear, we have almost no cases of Ebola from the prefecture of Gueckedou."
However, he warns: "This is very good news, but we still have to remain very vigilant. Because at Guéckédou, this is the third Ebola outbreak in the prefecture which ends today. So we are not immune to a fourth, if we can not control outbreaks around Guéckédou."
M. Poncin considers that there is always the risk that patients can come Macenta, Kissi-dougou or Sierra Leone to reinfect the prefecture. That is why he advocates vigilance. "We must be very vigilant. By cons, it's a good thing for the population of Guéckédou because today there is much less of transmission than in the past. Only Guéckédou, which was a very active center, which is virtually extinct, " he said.
Since the outbreak of the Ebola outbreak in March, MSF was alongside the Ministry of Health and today, alongside the national coordination against Ebola response to help end this epidemic. This decrease in contamination curve in the prefecture of Guéckédou said, is the result of better tracking of contacts and rigorous application of the measures imposed by the specialists in the fight against Ebola.
By cons, in Macenta, Gueckedou and neighboring prefecture border with Liberia, despite the strong involvement of nationals of that prefecture executives in awareness, lack of contact
tracing would still lacking. Consequently, in the only day on Thursday, four community deaths were recorded, according to a colleague based in the region.
The Guinea wanted to end the epidemic of Ebola by 2015. This target was not reached, it gives another. Now we expect to overcome the epidemic by the end of first quarter 2015. Wait-ing to see what will be done, we can ask what went wrong. And the coordinator of the fight against the epidemic answers the question.
According to Dir. Sakoba Keita, national coordinator of the anti-Ebola struggle, several factors have hindered the achievement of the objective. Among these factors, the coordinator confessed to the delay in the implementation of the accelerated response plan.
"We have fallen behind in the development of devices that had been identified in the ac-celerated plan for the fight," said Dir. Sakoba Keita. Before specifying that the financial re-sources were not available in time.
The second major factor mentioned by Dir. Sakoba is the reluctance of people. A reluc-tance that reflects the weight of prejudice and misunderstanding of messages about the disease. "We have repeated several times that the transmission of the disease is mainly with body fluids of infected people ..." recalled Dr. Keita.
The other factor that has not failed to point out is the "Guinea solidarity."
"We are also a victim of our spirit of solidarity. Instead of calling specialists, many fami-lies host their relatives suspected Ebola or they prefer to be healed by healers or imams," com-plains Dr. Keita. The leader of the fight against Ebola does not understand that his countrymen continue to deny the existence of the virus after 8 months of an outbreak.
Faced with the resurgence of Ebola outbreak in Guinea, the Minister of State for Mines and Geology began last Saturday, an information and awareness tour two days in several locali-ties in the region administrative Boke, found Guineenews.
Six weeks after its passage Kamsar, he returned his steps. This time, in addition to Kam-sar Kerfala Yansané visited Boke and Boffa Sangarédi. Before the start of his tour marathon, which started in Boke, the emissary of the head of state has previously had a working session with the support of health authorities.
A Boke and Kamsar, former treasurer of the country, who traded with wise men, women and youth, first made restitution of the report by the prefectural health director. While welcoming the non appearance of new cases Yansané nevertheless regretted what had previously produced Womey, Kouroussa Forécariah recently at Wanidara, where cases of reluctance or stressors of the Red Cross have been reported.
"It's really unfortunate that in some areas there is still some reluctance. How can we deal with people who came to help us end this epidemic or vandalize their vehicles, " lamented Ker-fala Yansané.
It is these acts, he said, that discourage partners who are supporting us in the fight against the Ebola outbreak. "How else to understand that countries that have a larger population that Guinea succeed in ending the epidemic in the space of forty days, while we, who do not even make fourteen million, were not able to overcome in a year?" he asks.
However, the Minister of State invited the people to call upon the agents of the Red Cross when a suspected case is reported. "We do not want to, but there are cases of death, call on the Red Cross workers. Because they are better equipped for this kind of situation, " he advised.
The first day ended with a visit to the pier and fishing port of Kamsar. In both places fre-quented by a cosmopolitan population, the Minister Yansané has an idea of the sanitary cordon set up.
At Sangarédi the second day of his tour, returning to the Ebola misdeeds, he, among oth-ers, dwelled on the closure of classes and Ebola-business. "In addition to the deceased by the fact of the Ebola virus, Ebola compromises the future of our children, which so far do not go to school. There are also some people who take advantage of Ebola resell chlorine available to us by partners, " denounced the minister who invited people to observe the preventive measures.
Then, before closing his speech, Kerfala Yansané announced that "when we have finished with the Ebola outbreak, representatives of mining, populations and those of the government will take place around a table to find ways and means so that mining is beneficial to all parties," he informed.
Seizing the opportunity, the spokesman youth pleaded for his family so that they are hired. After Sangarédi, the minister and several members of his cabinet led by Moussa Keita headed for Boffa where the tour information and awareness has ended.
As a contribution, in addition to ten flash thermo he put at the disposal of the Regional Di-rectorate of Boke, at each step, the state minister in charge of mines and geology offered the sum of three million Guinean francs.
The Office of International Coordination for the development of Télimélé (CIDT) learned with great surprise and regret that people considered contacts of the Ebola virus disease, rather than comply with the procedures laid down, have visited their original village, Bheygol in the sub prefecture of Sarékaly, Télimélé Prefecture.
On site, two people died and were buried by the community without bending the protocol that requires a secure burial; exposing innocent people who washed the body and those buried in contamination probabilities.
Unfortunately, the arrival of the medical team dispatched by the prefectural hospital for the latter, Friday, December 5, burial and funeral rites were all already completed. However, in-vestigations of doctors in the village have established an initial list of 25 contacts and identify two other patients who were evacuated to Ebola treatment center in Donka. And the removal of these two patients has certified that they are carriers of Ebola virus ...
Even before the evacuation of these two patients, some members of the CIDT office had exchanged with the prefectural authorities and health to better coordinate emergency actions. The availability of a small amount in Conakry allowed the citizens of Télimélé office in Conakry to take a first step pending a slightly wider mobilization.
Following a conference call, it was recommended to reactivate the local committee against Ebola and launch an emergency appeal for national coordination in the fight against Ebo-la, the government, the partner of Guinea, people of good will, as well as citizens, friends and supporters of Télimélé to provide financial and material support to the prefectural authorities and Health Télimélé that need to act quickly to prevent spread of a large scale of this serious disease.
CIDT ask all people of goodwill to liaise with the local committee against Ebola Télimélé chaired by Elhadj Alseyny Diallo, President nationals Télimélé in Conakry and in charge of monitoring and evaluation of international coordination for development Télimélé.
CIDT points out that they are our relatives who are threatened. So no one has to wait to be contacted individually to act. Everyone must mobilize and mobilize its side so that we can kill this evil in the bud. CIDT its sincere condolences to the bereaved families and asks each of our compatriots to mobilize against this danger that threatens our country and our people.
Guinea-Bissau will reopen on December 9 its borders with Guinea, closed since 12 Au-gust because of the current Ebola epidemic in West Africa, the government said Thursday in Bis-sau. The land border with Guinea Bissau Guinea is long over 300 km.
According to the Government, the reopening of borders was decided pursuant to a rec-ommendation made in November by the Economic Community of West African States (ECO-WAS), grouping 15 countries including Guinea-Bissau, as well as the Guinea, Liberia and Sierra Leone, the three most severely affected by Ebola.
The same source, the period of five days before the actual opening will take the necessary steps to strengthen the waypoints in human and material resources, including health.
"Our health care system still has flaws. But we will strengthen the capacity of men sta-tioned at these locations by equipping protection kits and equipping the rooms for isolation of suspected cases," he told AFP the director of Public Health, Nicolau de Almeida.
No cases of Ebola have been identified in Guinea-Bissau. August 12, Bissau announced the closure of the crossing points with neighboring countries and a series of accompanying measures - including the establishment of a hotline to report suspected cases, opening hospitals campaign and the urgent evacuation of suspected patients to health centers - to deal with any im-ported contamination.
Above: colorized image of the threadlike filovirus, Ebola Zaire.
Officially, a monitoring device was installed and isolation rooms furnished at border crossings. Local radio stations have been put to work to raise awareness. Collective ceremonies such as baptisms, weddings and funerals were banned.
The current outbreak of Ebola was 6.113 cases recorded 17,256 deaths in less than a year, mostly to Liberia, Sierra Leone and Guinea, according to a Thursday report published by the World Health Organization (WHO).
After the United States, it is Canada's turn to lend a hand in Liberia. The country has an-nounced the donation of hundreds of doses of another experimental vaccine to try to stem the epidemic of Ebola fever.
The days pass and nothing seems to block the spread of the Ebola virus raging in West Af-rica. The latest report published Monday by the World Health Organization (WHO) reported 1013 deaths, mainly in Guinea, Sierra Leone and Liberia. Faced with this problem, the govern-ments of countries called on the international community to help. The United States responded to the request of the Liberian President announcing the dispatch Monday in an experimental serum, Zmapp, which has been tested on two US humanitarian and in vain on the Spanish missionary, died of fever Monday.
In the aftermath of the US, Canada volunteered to deliver doses of another experimental treatment in Liberia. While no vaccine to date allows to treat the deadly virus Ebola, WHO con-siders that all means are good to try to curb the uncontrollable epidemic.
The "vaccine" sent by Canada was developed by scientists at the National Microbiology Laboratory of the Agency in Winnipeg. Like the Zmapp no guarantee to date its efficacy and ab-sence of side effects. It has never been tested on humans but only on animals.
Canada produced 1,500 doses of the vaccine, the manufacturing cost is very expensive, 800 to 1,000 doses are intended for Liberia. "Our government is determined to do everything possible to support our international partners, including the supply of workers to assist in the response to the outbreak and funding and access to our experimental vaccine," said Minister Federal Canadian Health Rona Ambrose.
This Canadian shipment is considered a case of force majeure. In fact, it will make emer-gency supply office and will be for humanitarian workers or doctors infected in the field.
Ebola hit hard Ambroise Paré, best equipped clinics in the capital Conakry. Three work-ers died of the virus and a fourth is under treatment. However, the clinic continues to work, argu-ing that her deceased employees were contaminated outside its premises.
The deceased workers are a driver and two doctors. The fourth employee who is under treatment, is a nurse. "He's much better," said Guineenews to a clinic doctor. This is the driver who died first. It was on December 1, a week after his admission to the Ebola treatment center. Three days later, the first doctor died. He was the emergency department. His case is different from that of the driver. He would have himself to the treatment center, as opposed to the driver who has been in the business channel.
The doctor would be contaminated in Forecariah where he had traveled in November. Ac-cording to information in our possession, it was he who would have contaminated the second doctor, his friend and colleague of the intensive care unit. This in turn is accused of contaminat-ing the nurse who would be better, according to a source of clinical outcome.
Investigations are underway to have all the details on these contaminations. Meanwhile, Dr. Conde tries to reassure: "These contaminations have nothing to do with the case that we re-ceived in October, which led to the suspension of our activities. None of us was found contami-nated after the 21 days following this case. All of these new infections are made outside our premises."
Ebola has killed pretty thousand people in Guinea. The victims included a good number of doctors and nurses who contracted the disease in the exercise of their functions.
The French authorities had announced! The anti-Ebola device started to be operational on Saturday at the international airport Charles de Gaulle in Paris, learned Africaguinee.com.
All passengers from Guinea have been subjected to temperature control. Among them, only one woman showed symptoms of an Ebola disease. It had a temperature higher than 38 ° C. The woman was from Guinea immediately taken over by the teams of the Bichat Hospital in Par-is.
According to a medical source, after some time, the temperature finally dropped below 38 ° C. Before taking their temperature all passengers were subjected to another exercise. They all filled out a form that would allow competent authorities to traceability in case of symptoms of Ebola disease.
FFIIGGHHTT AAGGAAIINNSSTT EEBBOOLLAA,, DDEECC 55
You should have received in your phone, a message saying: '' Orange African Union: To-gether we will defeat Ebola in Africa. Until 28/02 , make your donation by sending SMS "stop Ebola" in 7979 at a cost of 3000 FG '.This is none other than the campaign initiated by the Afri-can Union in collaboration with the telephone operators from different African countries.
In Guinea, two mobile operators are associated with this approach. This is Orange Guin-ea, the leader in mobile and Areeba MTN. This initiative of the African Union is to collect the most money as possible from subscribers to rid the continent of the Ebola hemorrhagic fever vi-rus which nowadays is more than 5 000 people in three (3) countries West Africa: Guinea, Sierra Leone and Liberia.
This Thursday, December 4, Orange Guinea has launched this campaign in its premises at Donka in the presence of an audience of journalists. Aim to inform the public that it can now help save lives against Ebola by simply sending a message (SMS) to the short number 7979 on Orange and MTN numbers at a cost of 3000 gnf / sms. A number that was courtesy of the Post and Telecommunications Regulatory Authority (ARTP).
According to the Director of Marketing and Communications of Orange Guinea, Abdoul Karim Bangoura "the funds raised will be donated to the African Union for the recruitment and training of nearly 1,000 health workers, awareness still reluctant in some areas and the purchase of medicines and consumables for countries affected by the Ebola virus," he reassured.
The company Orange Guinea invites all its subscribers the opportunity to participate in this civic gesture by sending as many messages as possible so that together we can finally eradi-cate the Ebola virus. A way for them to show their solidarity with their African brothers and sis-
ters affected by this virus. For this, Abdul Karim launches mobilization message to all the people of Guinea "that everyone does what he can," he said.
Present at the launch of that campaign, Tass Fode Sylla, head of communication at the national coordination of the response to Ebola was glad to support this Orange Guinea. "It's a joy for us that the phone companies mingles with the fight," he said, adding that "Ebola strangling the country of the system. Ebola weight is too heavy on the people, hotels, shops ... in short, the economic field."
Note that this telethon will last until February 28, 2015 . So go ahead, make your dona-tion by typing "stop Ebola" in 7979. You too can change lives as Orange, leader in mobile te-lephony in Guinea.
VVIIOOLLEENNCCEE IINN WWOOMMEEYY SSEEPPTT 1166
On 16 September, the inhabitants of the locality Womé killed with stones and sticks, eight members of a mission of information and prevention of Ebola virus. After the excitement, horror and amazement, this bloody massacre Womé is a message to the place Koro Alpha has found it necessary not to set foot!
Certainly, justice must be done to victims who among them, the sub-prefect of Womé, three journalists, the deputy director of the regional hospital in this tragedy N'zérékoré. But to see it closely, it is actually a coded message for Koro Alpha, the Mansa throughout Guinea.
First, this Womé killing reflects the failure of government communications to educate people on the dangers of Ebola. One member of this fatal mission Womé says: "The protesters suspected the team for coming to kill them because they believe Ebola is an invention of the whites to kill blacks!"
The people of Womé they are wild? No! The only certainty is the "lessons" of intellectuals whose arrogance and contempt towards local cultural realities, are not welcome the Aboriginal side. A resident of N'zérékoré native Womé tells the micro RFI: "for centuries our parents live in this village, they always ate bushmeat, n otamment bats. So why do you want us to ban it?"
Besides the fear of Ebola virus, this is also felt stigma towards some fellow from the for-est region (where bushmeat is popular, but is a vector of transmission) that starts the vicious cir-cle of violence. Koro, focus danger !
Second, the killing of Womé illustrates a sad evidence regarding the forest "out of sight, out of heart" they say. Very far from the capital Conakry, the forest area is not among the priori-ty of government Koro Alpha. Besides its predecessors have not done better for this rich and fer-tile region but lacks everything.
This feeling of abandonment is a burden for these people who have experienced the worst atrocities, who paid the direct and indirect consequences of the fratricidal wars in Liberia, Sierra Leone and Côte d'Ivoire?
This is the forest! A do we forget the inter-ethnic conflict between koniankésand Guerzé (hundreds of deaths, including Koule in July 2013)? What about the massacres of Zogota in Au-gust 2012 when security forces fired on peaceful people in their sleep? At each of these abuses, the Guinean government uses the same recipe: index rebel groups Etrangers and sending frames nationals in the area to extinguish the fire. Koro, attention danger!
Third, the Womé killing confirms the sad reality that the Guinean no longer believe in their righteousness because of impunity and the feeling of growing insecurity in the country. Look, last week, Amadou Oury Diallo active member of the Union of Democratic Forces of Guinea (UFDG) of Diallo was killed in cold blood at his home in Conakry.,,"
BBUUSSHHMMEEAATT
Only recently did I become aware of the fact that bushmeat, a purported vector for the Ebola virus, was a risk to the US and other outside Africa countries. Bushmeats consist of a vari-ety of animal meats, frombat to monkey to lion, including a number of endangered species. Alt-hough it is illegal in the U.S. the cache it carries ensures that tons of bushmeat enter the country [and other countries] for consumption by large communities of west Africans.
For instance, there are ~ 77,000 west Africans. For many, bushmeat is a luxury and a deli-cacy and it is obtainable. US Customs states that imports of bushmeat, a potential vector for Ebo-la and other serious diseases, is ~ 15,000 pounds per month. Although small studies have not de-
tected Ebola virus in imported bushmeat, other viruses such as monkeypox have been detected. The threat this poses for domestic populations of an Ebola virus outbreak, is significant.
The number of deaths due to the outbreak of Ebola hemorrhagic fever in the three most af-fected countries in West Africa amounted to 6,331 deaths out of 17,800 cases, according to the latest report of the World Health Organization Health, arrested December 6 and on Monday.
Sierra Leone became for the first time the nation with the largest number of people infect-ed with Ebola virus, with 7,798 recorded cases against 7719 in Liberia. A previous review, dated December 2, reported dead in 6070 a total of 17,145 people infected with the virus. The epidem-ic, the worst since the identification of the virus in 1976, is part of Guinea in late December 2013. December 6, was recorded in the country 1412 deaths 2283 cases.
In Sierra Leone, WHO has identified 6 December 1742 deaths on 7798 cases. There are now more cases Ebola in Sierra Leone in Liberia. In Mali, the latest country hit by the virus, WHO reported 8 cases that caused 6 deaths.
The record in Nigeria and Senegal is unchanged for two months, with 20 cases and 8 deaths in Nigeria and one case in Senegal, a Guinean student whose cure was announced by the authorities on 10 September.These two countries have been removed from the list of those plagued the epidemic.
OOUUTT OOFF AAFFRRIICCAA
In the United States, four cases were registered but only a Liberian patient, back in his country, has died from the disease, according to the balance sheet as at 16 November. (A Sierra Leonean doctor evacuated to the United States died there on 17).
Spain was declared free of the virus last Tuesday by WHO after 42 days have elapsed without further contamination. Spain had experienced a case of infection, a nurse's aide who had occupied two missionaries contaminated and repatriated in Madrid where they died in August and September. The nurse has since been declared cured.
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As part of the continuing fightback campaign against the viral haemorrhagic fever Ebola in our country, the government intensified actions in the deep Guinea. Patron of the city of Labe, Minister Mamadou Aliou Diallo Transport chaired a conference of awareness against Ebola this Tuesday, December 9, 2014, in Labe, is it found on site.
The prefecture conference room was the setting for the ceremony that demonstrated the new strategy taken by the government to kick Ebola outside our borders. Now, the ministers will personally invest, says Aliou Diallo. "The purpose of these missions is that all members of the government go to the prefectures and they are expressed in local language to convey the mes-sage of the President of the Republic and the Government with respect to control devices against this disease," he begins the minister.
In the debates, the sub prefect of Hafia (town housing the university center of Labe) raised the issue of student management issue. "I caught the attention of Minister and the accom-panying delegation on the fact that the University of Hafia opening soon. So, it would make ar-rangements to receive students from localities Forest. 40% of students are generally Forest.
So prevention is better not only the authorities at all levels and citizens who host them. It is not to stigmatize them, but it is to put observation until arrangements are made to see if they are carrying the virus or not," said Mamadou Barry Yero, sub-prefect of Hafia.
In response, the minister had assured that every effort will be put in place before the opening of classes. "For education services what is the system set up? Is he lapped? Is all the training that had to be done have been done? Does inputs that were to arrive arrive?
How happens? We will do concretely. So we will liaise with the rector of the university in question and services to ensure that the measures taken before the start of school are already operational. Because what you say, it is more than important," reassures Aliou Bah. To believe our sources, the Minister Aliou Diallo will rally Popodara, Kouramangui, Sannoun and Dionfo before returning to Conakry.
TTRROOUUBBLLEE IINN WWEESSTT AAFFRRIICCAA
The next section of this chapter provides information related to the beginnings of the cur-rent Ebola epidemic, as reported in the general media and scientific reports.
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Sometime in late November 2013, unremarked by the rest of the world, something terrible appeared in a remote corner of Guinea, a small country in west Africa. The first indication of fu-ture troubles was the sudden, unpleasant death, of a few villagers. The victims were taken down by a mysterious illness that rapidly progressed from an initial fever, to a total body meltdown in just a few days. This frightening disease was initially localized geographically to a small remote village, Meliandou, Guinea.
MMEELLIIAANNDDOOUU
The GE image below depicts Meliandou village in relationship to Kenema in Sierra Leo-ne, and Monrovia, the capital of Liberia. The view is to the west with the Atlantic Ocean in the distance. Meliandou is "remote" mostly because the roads are so bad. But it's located just 100 miles from Monrovia. Also shown is the three corners region, where Guinea, Sierra Leone and Liberia come together.
Remoteness also can refer to the cultural distance of a location. In general in this region, the more physically isolated a region is, the lower the general education level of the population and the greater the belief in nonrational explanations for everything. In the age of Facebook however, this correlation of remoteness and culture will likely fall by the wayside.
The village of Meliandou is located within the Guinean forest region. However, I've read a few papers that document the fragmentation of the natural environment in the region in which Meliandou is located. Former forests have be logged to the point where the landscape consists of only fragments of forest interspersed with cleared areas.
The intrusion of mankind into the forests in this manner could be responsible for bringing humans into contact with Ebola virus which theoretically resides in an unknown animal reservoir in these forests.
As I reviewed the available information on the early days of the Ebola epidemic, a key question frequently came into mind: why did the growing number of early Ebola deaths not set off any alarm bells in the outside world?
BELOW: A GE image of the clearing in which the village of Meliandou is located.
Breaking out from Meliandou, the deadly virus spread almost unnoticed through Guinea. The major epidemic smouldered almost undetected for more three months. The medical profes-sion had an early headsup because, as in previous Ebola outbreaks, hospitals make great Ebola incubators. Likewise, if Ebola isn't known to exist in the neighborhood, physicians will work with sick patients without using the special PPE that is a life saver when dealing with Ebola in-
fected persons.
MELIANDOU CLEARING
Health workers, nurses and doctors, believing they were dealing with cholera or Lassa fe-ver, suffered disproportionately to other segments of the population. In fact, of the first 15 deaths in this Ebola outbreak, 4 were health care personnel.
TTHHEE IINNDDEEXX CCAASSEE
As in previous Ebola outbreaks, in the 2014 outbreak the identity of the first person in-fected by the virus was unknown. Likewise, how Ebola found its way to the region remained a mystery. Months after the onset of the epidemic however, a research team studying the Guinea outbreak traced the disease back to a 2-year-old boy who died in Guéckédou Prefecture on De-cember 6, 2013.
Above: Etienne Ouamouno holds photographs of his wife Sia and two children Em-
ile and Philomene, the first known victims of this Ebola outbreak. Two year old Emile Ouamouno lived in the remote Guinean village of Meliandou. In early December 2013 the youngster began suffering from fever, headache and developed a bloody diarrhoea.
Their report published in the NEJM, suggests this youngster the index case, although that could not be established with certainty. He and his relatives who had died, were never tested to confirm Ebola. Their symptoms matched those of a typical Ebola infection and the contagion was transmitted from person to person in a pattern consistent with transmission of Ebola virus. As to why this small boy became the first person in west Africa ever infected by Ebola virus, no
one knows.
Sylvain Baize, part of the team that studied the Guinea outbreak and head of the national reference center for viral hemorrhagic fevers at the Pasteur Institute in Lyon, France, said that prior to the 2 year old boy's infection with Ebola, there might have been an earlier case that went undiscovered.
"We suppose that the first case was infected following contact with bats," he said. "May-be, but we are not sure."
Around December 6, 2013, despite his family's best efforts, the young boy died. Within days, his three-year-old sister Philomene died followed by his pregnant mother Sia and then his grandmother. All victims developed fever, vomiting and diarrhea, but at this time, no one knew what had sickened them.
The grandmother's funeral served as a locus from which the virus estended it's reach deep-er into Guinea. Two mourners at the grandmother's funeral took the virus home to their village. A health worker carried it to still another, where he died, as did his doctor. The worker and the doctor had both infected relatives from other towns before their deaths.
By March, when the "fingerprint" of Ebola virus was recognized, dozens of people had died in eight Guinean communities. Suspected cases if EVD were now popping up in Liberia and Sierra Leone. Guinea, Sierra Leone and Liberia are three of the world's poorest countries.
In 2014 they had unstable governments and were plagued by corruption. These countries were victims themselves, still recovering from previous years of political dysfunction and civil war. None possessed a health care infrastructure worthy of the name. This picture of the Ebola epidemic's origins was constructed piece by piece as information and evidence became available in the six months after the epidemic began. As noted earlier, the identification of the Ebola virus as the source of contagion, occurred at the end of March 2014.
A few months later, the identity of the index case had been determined. The name of little Emile Ouamouno was released in October 2014, nearly a year after his untimely death from EVD.
TTHHEE OOUUTTBBRREEAAKK BBEEGGIINNSS
The figure below, from the NEJM, depicts the most likely sequence of events as Ebola spread from the index case, Emile. This reconstruction of the sequence of events in the early stages of an outbreak or epidemic, is key to determining the circumstances of the sentinel event --- what is the causitive agent?
Where did it come from? Why did it appear here? And now? What factors govern the transmission of the infectious agent? What's the incubation peri-
od? What's the R0? And so on. Determining the answers to these and other key questions allows an accurate understanding of the contagion to be created.
This knowlege is usually a prerequisite to implementing appropriate and effective coun-termeasures, though basic principles of epidemiology are useful even in situations where there is only unknowing and mystery surrounding an outbreak of contagion.
MMAARRCCHH 3300 FFIIRREESSTTOONNEE
In Guinea by the end of March 2014, the virus was reaching towards the capital Conakry. By March 30 the virus had struck Liberia, appearing in the Firestone Rubber Plantation not far from Monrovia. This circumstance resulted in a rare, feel good Ebola story, though it wasn't, and isn't, commonly known.
Above: a NEJM graphic depicting the region around Guedkedou where the Ebola virus first appeared and then it's subsequent move into the capital city of Guinea, Conakry.
Firestone is big in Liberia, some Liberians allege it's too big. In 1926 the founder of the
Firestone Tire and Rubber Company, Harvey, reached an agreement with the government of Li-beria to lease 1 million acres to establish one of the world's largest rubber tree plantations. This plantation evolved into an almost country in itself, with its capital at Harbel.
The sprawling, 185-square-mile plantation, filled with rows of dappled rubber trees which
cover Harbel's entire landscape. Prevailing winds cause the adult trees to lean westward. Back when Firestone was still based in Ohio, employees used to joke that the trees are "bowing to Ak-ron."
Firestone is the largest employer in Liberia. Firestone runs it's own first rate school sys-tem, operates it's own medical system, provides it's own communities [with more than 80,000 Liberian residents] with fire, police and other services.
Firestone's classic slogan is "where the rubber meets the road." In 2014, the Ebola virus rubber met the Firestone road in Harbel Liberia, on March 30. That day, the wife of a Firestone employee, traveling from northern Liberia, arrived on the plantation. She had cared for an ailing woman in the north, who later was diagnosed with EVD. Then she herself was diagnosed with the Ebola virus disease.
Above: Map depicting the geographic locus of a contagion, which was discovered on
March 23, to be due to Ebola virus.
When the Ebola case was diagnosed, "we went in to crisis mode," recalls Ed Garcia, the managing director of Firestone Liberia. He redirected his entire management structure toward Ebola.
Garcia's team first tried to find a hospital in the capital to care for the woman. "Unfortu-nately, at that time, there was no facility that could accommodate her," he says. "So we quickly realized that we had to handle the situation ourselves."
The case was detected on a Sunday. Garcia and a medical team from the company hospital spent Monday setting up an Ebola ward. Tuesday the woman was placed in isolation. "None of us had any Ebola experience," he says. They scoured the Internet for information about how to treat Ebola.
They cleared out a building on the hospital grounds and set up an isolation ward. They grabbed a bunch of hazmat suits for dealing with chemical spills at the rubber factory and gave them to the hospital staff. The suits worked just as well for Ebola cases.
Firestone immediately quarantined the woman's family. Like so many Ebola patients, she
died soon after being admitted to the ward. But no one else at Firestone got infected: not her family and not the workers who transported, treated and cared for her. The Firestone managers had the benefit of backing and resources of a major corporation -- something the communities around them did not.
Firestone didn't see another Ebola case for four months. Then in August, as the epidemic raced through the nearby capital, patients with Ebola started appearing at the one hospital and several clinics across the giant rubber plantation. The hospital isolation ward was expanded to 23 beds and a prefab annex was built. Containing Ebola became the number one priority of the company. Schools in the town, which have been closed by government decree, were transformed into quarantine centers. Teachers were dispatched for door-to-door outreach.
Hundreds of people with possible exposure to the virus were placed under quarantine. Seventy-two cases were reported. Forty-eight were treated in the hospital and 18 survived. By mid-September the company's Ebola treatment unit was nearly full. By the end of October, how-ever, only three patients remained: a trio of boys age 4, 9 and 17. "So we have these three," says Dr. Benedict Wollor, coordinator for the Ebola treatment unit at Firestone. "We are concerned because by this morning the 4-year-old was just crying
A team is getting dressed in full body suits, gloves and goggles to enter the ward: a doctor, two nurses and a man with an agricultural sprayer full of disinfectant strapped to his back. Wol-lor says the team has a lot of work to do before they get overheated in their industrial spacesuits.
"They have to change Pampers, bedding, even bathe them," says Wollor. "Make sure they're clean. If someone is dehydrated, open an IV line. Imagine how we maintain an IV line on a kid."
These three boys all came from outside the plantation. So even as the worst Ebola out-break ever recorded rages all around them, Firestone appears to have blocked the virus from spreading inside its territory.
Firestone's remarkable job of keeping Ebola virus at bay isn't widely known. Dr. Brendan Flannery, the head of the U.S. Centers for Disease Control and Prevention's team in Liberia, has hailed Firestone's efforts as resourceful, innovative and effective. Dr. Flannery said the a key reason for Firestone's success is the close monitoring of people who have potentially been ex-posed to the virus -- and the moving of anyone who has had contact with an Ebola patient into voluntary quarantine. Asked what's needed to turn the west African Ebola epidemic around, Dr. Flannery said, "More Firestones" -- you need money, resources and unwavering determination to stop Ebola.
On May 24, 2014, the first case of EVD in Sierra Leone appeared in the form of a young woman admitted to a government hospital in Kenema following a miscarriage. Ebola virus by now, was on the radar screens of the regions health care workers. Consequently, this woman was tested for Ebola at the time of her admission and placed in isolation on 25 May; the results were positive.
The virus had finally [officially] reached Sierra Leone. WHO was notified by the Ministry of Health and Sanitation almost immediately. This initial presentation of EVD in Sierra Leone benefited from the knowledge gained elsewhere about what not to do. In Sierra Leone, when the woman presented, all the right precautions were taken. No one else at the hospital, neither pa-tients nor medical staff, contracted Ebola virus disease. Best of all, the young woman made a full recovery.
Unfortunately, this first case and it's disposition, was an anomaly. Thereafter, the Ebola virus situation in Sierra Leone went downhill.
The role of traditional funeral practices in facilitating the spread of Ebola virus was known from even the earliest outbreaks. In Guinea, 60% of all cases had been linked to tradition-al burial practices. But, this knowledge didn't effectively protect Sierra Leone from a minidisas-ter within the larger disaster.
A widely-respected traditional healer lived in the Kenema region of Sierra Leone, near to the region in Guinea in which Ebola had first appeared. She was consulted by a number of ill and desperate Ebola infected persons from Guinea. The healer became infected and subsequently
died. Her fame drew mourner from a large region, by the hundreds. Health officials later estimat-ed that this one funeral was linked to 365 EVD deaths in those who attended.
Kenema Government Hospital already had a well-equipped isolation ward – in fact, the only Lassa fever isolation ward anywhere in the world. Initially, the country's Lassa Fever Pro-gramme used its contact-tracing staff and skills to try to contain the outbreak, but that capacity was rapidly overwhelmed. Several nurses working there were quickly infected, and 12 of them died. Nearby Kailahun district became the country's second major hotspot.
Ebola virus quickly made it's way into the capital city, Freetown, where it took advantage of overcrowded living conditions and fluid population movements to expand almost exponential-ly.
Estimates of the human toll from EVD in Sierra Leone were alarmingly high. Unfortu-nately, authorities quickly realized that the reality was even worse than suspected. Many reports described burst of disease in which the populations of entire villages died. This means up to 20,000 people could have succumbed to the disease by now, a senior coordinator for Doctors Without Borders (MSF) believes. Rony Zachariah, coordinator of operational research for MSF, emphasized the fact the Ebola impact on Sierra Leone is "under-reported."
"The situation is catastrophic. There are several villages and communities that have been basically wiped out. In one of the villages I went to, there were 40 inhabitants and 39 died," Zachariah told the agency. "Whole communities have disappeared but many of them are not in the statistics. The situation on the ground is actually much worse. The WHO says there is a cor-rection factor of 2.5, so maybe it is 2.5 times higher and maybe that is not far from the truth. It could be 10,000, 15,000 or 20,000."
Zachariah also highlighted the shortage of healthcare workers in the country.
"You have one nurse for 10,000 people and then you lose 10, 11, 12 nurses. How is the health system going to work?" he said. Even at this point, the pace of dealing with Ebola is slow, he added. "We might get a vaccine and a treatment...but even now we need to go much faster be-cause the clock is ticking...We want action now."
DDRR.. KKHHAANN [[RREEUUTTEERRSS]]
Dr. Sheik Humarr Khan, a 39 year old native of Sierra Leone, ran the Lassa Fever pro-gramme in Kenema. He was a virologist with a world-wide reputation for expertise in viral hem-orrhagic ffevers. In addition to his global reputation, in Sierra Leone he was a national hero. Dr. Khan is a co-author of the Science study published September 12, 2014 [discussed elsewhere]. This study confirmed that the healer's funeral [also mentioned elsewhere] as a seminal event at the outbreak's explosive start.
In late July Dr. Khan developed a fever. He was rushed to a treatment unit run by Medecins Sans Frontieres (MSF) where doctors debated whether to give him ZMapp, a drug tested on laboratory animals but never before used on humans. Staff agonized over the ethics of favoring one individual over hundreds of others and the risk of a popular backlash if the untried treatment was perceived as killing a national hero.
In the end, they decided against using ZMapp. Dr. Khan died on July 29, plunging his country into mourning. A few days later, the California--manufactured pharmaceutical was ad-ministered to U.S. aid workers Kent Brantly and Nancy Writebol who contracted Ebola in Libe-ria and were flown home for treatment. It is not clear what role ZMapp played in their recovery but the two left hospital in Atlanta last week.
Dr. Khan is among nearly 100 African healthcare workers by July 2014, to have paid the ultimate price for fighting Ebola, as the region's medical systems have been overwhelmed by an epidemic which many say could have been contained if the world had acted quicker. In their vil-lage of Mahera, in northern Sierra Leone, Khan's elderly parents and siblings asked why he did not get the treatment. Khan saved hundreds of lives during a decade battling Lassa fever -- a dis-ease similar to Ebola -- at his clinic in Kenema and was Sierra Leone's only expert on hemor-rhagic fever.
Victims suffer vomiting, diarrhea, internal and external bleeding in the final stages of the disease, leaving their bodies coated in the virus. To treat the sick, doctors require training and protective clothing, both of them scarce in Africa.
This outbreak -- the first in West Africa -- was detected five months ago deep in the for-ests of southeastern Guinea. But it was not until Aug. 8 that the World Health Organization de-
clared an international health emergency and promised more resources. By decimating healthcare staff in countries that had only a few hundred trained doctors before the outbreak, Ebola has now left millions vulnerable to the next crisis, experts say.
"Dr. Khan knew the risks better than anybody ... but if you work for months in overcrowd-ed facilities, 18 hours a day, anyone will make a mistake," said Robert Garry, professor of mi-crobiology and immunology at Tulane University in New Orleans, who worked with Khan for a decade.
"The whole international community needs to look back and say we dropped the ball. We should've reacted faster to this."
To many in his impoverished country, Khan was a saviour for his pioneering work with Lassa fever, a disease endemic to the jungles of eastern Sierra Leone that kills 5,000 people a year. When Ebola struck, he became a figurehead for that fight, too, hailed by President Ernest Bai Koroma as a "national hero".
Khan knew from the first his work at the Kenema clinic would be dangerous. When he took over as head doctor there in 2004, his predecessor had bled to death from Lassa fever in the same ward. But after 11 years of civil war, there were few others who could do the job.
Above: Dr. Khan
The last but one of 10 children from a humble background, Khan always wanted to be a physician like his childhood hero Dr. Kamara, who ran a clinic in Mahera. Determined to enter Freetown's medical school COMAHS, Khan persisted despite being initially rejected. When he graduated, his father was too ashamed to visit this preserve of his country's elite and listened to the ceremony on the radio.
"When the name Dr. Sheik Umar Khan was called out by the dean of the faculty, my fa-ther broke down in tears of joy," Khan's sister Mariama recalled.
An extrovert and joker, Khan threw himself into his work in Kenema, a diamond--trading hub home to 130,000 people. His wife divorced him, complaining he only had time for his pa-tients. When Ebola struck, Khan converted the bungalows of the clinic into an Ebola treatment center, erecting a makeshift tarpaulin ward outside with 50 beds in three rows. With no proven
cure, doctors simply tried to keep patients hydrated and free from other diseases as Ebola at-tacked their immune system.
Though he feared for his life, he refused to abandon the understaffed clinic, even as nurses there began to fall sick. "If I leave, then who will come and fill my shoes," he told a friend from medical school, James Russel.
One of Khan's biggest challenges was resistance from local people, terrified of the medics in their white bodysuits and masks. A crowd attacked the Kenema facility, enraged by a rumor of cannibalism there. Several patients fled, spreading infection even wider.
"My biggest problem ... is getting people to accept the disease," a frustrated Khan told Reuters in June. The first person infected in Sierra Leone was a "sowei" -- a tribal healer. She claimed to have the power to treat Ebola and had attracted sick people to visit her from Guinea. Traditions of washing the dead helped spread the disease. Several women from neighboring towns were infected at the sowei's burial.
Already thinly staffed, the clinic was sapped by resignations and a strike after three senior nurses died. Khan was compulsive in checking his protective gear before entering the ward, us-ing a mirror he called his "policeman".
"I'm afraid for my life because, I must say, I cherish my life," he said. Bausch, sent by the WHO to Kenema in July to help train staff, said Khan had appeared worn down. Bausch had hired Khan to work at the Kenema clinic in 2004 but was so alarmed by the understaffing there, he had wondered if it should be shut down.
"It's one thing for a foreign doctor who comes in for three weeks. But if you're Dr. Khan, head of the ward, it never stops," Bausch said. "Anyone would get infected."
Khan's death sent shockwaves through Sierra Leone's small medical community of less than 150 doctors for its 6 million people -- one of the lowest ratios in the world. Sierra Leone has one doctor per 45,000 inhabitants, according to the WHO, compared to a doctor for every 410 people in the United States. Other senior medical staff in the country have since died and the staff at Kenema has been decimated
Richard Preston in "Outbreak" also wrote of Dr. Khan. The paragraphs below are taken from this article.
...In Sierra Leone, in the town of Kenema, eighteen doctors and nurses who had been working in the Lassa/Ebola ward have contracted Ebola, and at least five have died. They had been working in biological-hazard suits, yet they got sick anyway. People are wondering if the virus could spread to Europe or the United States, but the more immediate question is whether it could infect a whole lot more people in Africa. A particle of Ebola-Zaire virus is made of only ten proteins, locked together in what looks like a tangle of string. Despite its extreme simplicity as an organism, when Ebola strikes a human it becomes a killing machine, the biological equiva-lent of a steel axe.
The virus is transmitted from one person to the next through contact with blood or other bodily fluids. The symptoms of the disease start out looking like those of malaria: the patient runs a fever and feels weak. Ebola patients proceed to vomiting and diarrhea, which sometimes turns black; and they can develop hiccups. Fewer than half the patients in this outbreak have shown signs of hemorrhage: pinpoint droplets of blood can sometimes glisten on the rims of the eyelids. Around sixty per cent of the victims have died.
In July, as the outbreak gathered force, Daniel Bausch, an American doctor and Ebola ex-pert, arrived in Freetown, Sierra Leone, and proceeded on to the Lassa/Ebola ward in Kenema, a facility that he helped set up. The hospital is a cluster of small cinder-block buildings in the cen-ter of town.
He put on personal protective equipment, known as P.P.E.--a type of biohazard gear that consists of a Tyvek whole-body suit, a Tyvek hood with an opening for the eyes, safety goggles, a breathing mask over the mouth and nose, two pairs of nitrile gloves, a plastic apron, and rubber boots--and he walked into one of the Ebola wards, a makeshift structure with walls made of plas-tic film.
There he found the director, Dr. Sheik Humarr Khan, and a nurse wearing biohazard suits and taking care of thirty Ebola patients. "The floor was splashed with blood, vomitus, feces, and urine," Bausch said recently. Patients in the throes of Ebola often fall out of bed. "You need a whole team to decontaminate the bed and lift the patient up off the floor and put him safely back
in bed." Khan and the nurse were overwhelmed.
Some Ebola nurses had stopped coming to work: they had been working twelve-hour days, in biohazard suits, and they were supposed to be earning an extra thirty dollars a week in hazard pay, but the government of Sierra Leone had not provided it. Not unreasonably, many nurses had stopped showing up.
Last month, Joseph Fair, an American doctor who had worked in the ward, arrived to help in Kenema. He considered Khan one of his best friends, and told me that he regarded the chief nurse, a woman in her fifties named Mbalu Sankoh, who'd helped run the Kenema ward for twenty-five years, "as more or less a mom to me." He embraced Mbalu when they met, and he warmly greeted another old friend, a senior nurse named Alex Moigboi.
Two days after Fair's arrival, Nurse Mbalu developed a fever. She placed herself in a bed in the Kenema hospital and gave herself an I.V. drip, and told people that she thought she had malaria. Eight days later, she died. Since he had embraced her, Dr. Fair began testing his blood for Ebola virus. Alex Moigboi died shortly afterward.
For weeks, Dr. Fair has been going to funerals in Kenema. "I just couldn't keep it together at Mbalu's funeral," he said last week. He was in Freetown, and had just returned from the fu-neral of Dr. Khan. "The ones who have passed are the only ones who would go into the Ebola ward," Fair said. "Now we have a huge void." He recounted how Dr. Khan, as he lay dying in the ward he had run for ten years, had whispered to a fieldworker, "James, I am going. You have to carry on."
Humarr Khan was working in the Ebola wards. When he came out, and had stripped off his P.P.E., Gire thought that he seemed exhausted and tense. Khan met regularly with interna-tional aid workers, and he made countless calls on his cell phone to representatives from the World Health Organization and officials from the Sierra Leone Ministry of Health, pleading for more help, more resources.
He called family members -- he had nine brothers and sisters, some of whom lived in the United States, and his parents were still alive, in Lungi, a town not far from Freetown, the capi-tal. He spoke with Pardis Sabeti; he planned to join her group at Harvard in a few months. He was fascinated by genomics and he wanted to know how the sequencing of Ebola was going.
He couldn't stand the bureaucracy of the outbreak, Sabeti told me, and he would return to the Ebola wards as if they were a refuge from trouble. He seemed more at ease wearing P.P.E. and caring for patients. Khan had been running the Lassa program for almost a decade.
In 2004, his predecessor, Aniru Conteh, accidentally pricked himself with a needle con-taminated with blood from a pregnant woman who had Lassa. Conteh died twelve days later, of Lassa fever, tended by his own nurses. For months, the government couldn't find any doctor will-ing to run the Lassa program. Khan, who had just finished his internship at the Sierra Leone Col-lege of Medicine, agreed to take the job.
Khan arrived driving a battered old car. He was thirty, a modest, handsome man who smiled and joked playfully with people. Khan took up his work and gave patients exceptional attention. One day, a U.S. graduate student named Joseph Fair fell desperately ill with bloody diarrhea. Khan paid a visit to Fair at his room in a nearby Catholic mission, and that was when Fair discovered that Khan had a beautiful bedside manner.
After prescribing antibiotics, Khan jovially said to him, "You'll be fine." But, leaving the room, Khan forgot to close the door. Moments later, Fair heard him blurt out to somebody, "This guy is dying! I can't have an expat die on me!"
Fair got better, and he and Khan soon became friends. A few years later, they were having a beer in a bar in New Orleans when Fair told Khan that the first time they met he had heard Khan say he was dying.
"Well, you were dying," Khan answered.
Fair said, "You didn't tell me." Khan burst out laughing. "I would say you were dying? You were my patient. Can you im-
agine?"
Khan worked long hours in the Ebola wards, trying to reassure patients. Then one of the nurses got sick with Ebola and died. She hadn't even been working in the Ebola ward. The virus particles were invisible, and there were astronomical numbers of them in the wards; they were all over the floor and all over the patients.
Around July 12th, Joseph Fair, who had been working with the World Health Organiza-tion in Freetown, two hundred miles away, travelled to Kenema, a drive of several hours, and went looking for his friend Dr. Khan. Fair found him but couldn't speak with him, he told me lat-er.
Khan was inside the plastic Ebola ward, and the place was a mess. There were thirty or more Ebola patients in the ward, lying on cholera beds, and the floor was splashed with every-thing that can come out of the human body. Khan was making rounds, with one nurse, both of them wearing P.P.E.
Daniel Bausch, an American Ebola doctor who had been helping at Kenema, and his col-leagues recently wrote that Khan had remarked, "I am afraid for my life, I must say. . . . Health workers are prone to the disease, because we are the first port of call for somebody who is sick-ened."
They also quoted Khan's sister Isatta as saying, "I told him not to go in there, but he said, 'If I refuse to treat them, who would treat me?' " Perhaps Khan was thinking of his predecessor Dr. Conteh, dying in his own ward.
Alex Moigboi, a popular man who had worked in the hospital for many years, came down with Ebola. Then the head nurse, Mbalu Fonnie, a widow who sometimes used the last name Sankoh, and who had worked at the hospital since it opened, in the nineteen-nineties, began feel-ing weak and shivery and ran a fever. At first, she downplayed her symptoms and continued working seven days a week, fourteen to sixteen hours a day.
She hoped that she had malaria, and gave herself an I.V. drip of malaria medicine, but she didn't get better. She tested positive for Ebola. That same day, two other Kenema nurses, Fatima Kamara and Veronica Tucker, also tested positive for Ebola. Moigboi died on July 19th, and Fonnie died two days later. Many of the staff at Kenema became terrified and began staying home from work. Khan ended up working in the Ebola wards with little or no support.
Sierra Leone's medical-care system, sparse and rudimentary to begin with, was collapsing under the strain of Ebola, and the international aid groups that worked in Ebola outbreaks were stretched thin. Doctors Without Borders was coping with Ebola patients in a treatment center at Kailahun, in eastern Sierra Leone, fifty miles from Kenema. In Liberia, doctors and nurses with Samaritan’s Purse, a Christian organization, were overrun with patients at a hospital called ELWA, near Monrovia. Khan talked regularly with Pardis Sabeti.
"We are all alone here," he said to her one day. She told him that she and her colleagues in the War Room were rushing people and equipment to him, and they were calling around the world, looking for more doctors and more help. "People and help were coming," Sabeti told me later, "but it was nowhere near enough."
Sabeti warned Khan about stress and overwork. "The most important thing is your safety. Please take care of yourself." He told her, "I have to do everything I can to help these people," and then he would put on his gear and go back into the Ebola wards.
Khan was a general in a battle where many of his troops were dead or fleeing. On July 19th, at a large staff meeting, people noticed that Khan didn't look well. The next day, he didn't come to work. He had isolated himself at home. The following morning, he requested a test. One of the lab technicians went to his house to draw blood: it was positive for Ebola.
Khan didn't want to be treated at Kenema, because he didn't want his staff to see him de-velop symptoms, and he felt that his presence would further demoralize them. The next day, he climbed into an ambulance, which carried him along rutted dirt roads to the Ebola ward in Kailahun.
... At two o'clock in the afternoon on July 31st, the funeral of Humarr Khan began in Kenema. It was attended by five hundred people, including townspeople, scientists, health work-ers, and Sierra Leone government ministers. Many wept uncontrollably. The gravediggers en-countered rocks, and it took them hours to dig deep.
At ten o'clock that night, in the moments when Kent Brantly was shaking with rigors as ZMapp flowed into his body, the gravediggers finished burying the body of Khan at the Kenema hospital.
As Khan lay dying, Pardis Sabeti composed a song for him and the other Kenema work-ers, called "One Truth." It had the line "I'm in this fight with you always." She had hoped that some day she could sing it to him, but by then he was already in isolation. When she received the
news of his death, she was "absolutely devastated," she said. "I can't even begin to describe the feeling of loss for the world."
Equally devastating were the deaths of the staff members who had stayed to work in the wards at Kenema. Through the summer, Sabeti and her group continued to read the Ebola ge-nomes. They published them in real time, on the Web site of the National Center for Biotechnol-ogy Information, so that scientists anywhere could see the results immediately.
Then, in late August, they published a paper in Science detailing their results. They had sequenced the RNA code of the Ebolas that lived in the blood of seventy-eight people in and around Kenema during three weeks in May and June, just as the virus was first starting chains of infection in Sierra Leone.
The team had run vast amounts of code through the sequencers, and had come up with around two hundred thousand individual snapshots of the virus, in the blood of the seventy-eight people, and had watched it mutate over time.
They could see who had given the virus to whom. They could see exactly how it had mu-tated each time it grew in one person and jumped to the next. The snapshots, taken together, amounted to a short video of Ebola.
You could imagine the virus as a school of fish, with each particle of Ebola a fish. The fish were swimming, and as they swam and multiplied they changed, until the school had many kinds of fish in it and was growing exponentially in size, with some kinds of fish better at swimming than others.
...Gire and Sabeti's group also found that the virus had started in one person. It could have been the little boy in Meliandou, but there is no way to tell for sure right now. After that, the swarm mutated steadily, its code shifting as it palpated the human population. As the virus jumped from person to person, about half the time it had a mutation in it, which caused one of the proteins in the virus to be slightly different.
By the time the virus reached Sierra Leone, travelling in the bodies of the women who had attended the funeral of the faith healer, it had become two genetically distinct swarms. Both line-ages of the virus moved from the funeral into Sierra Leone. Already, some of the mutations were making Ebola less visible to the tests for it.
The Science paper included five authors who died of Ebola, including Humarr Khan, the head nurse Mbalu Fonnie, and the nurse Alex Moigboi.
"There are lifetimes in that paper," Sabeti said.
Below: Dr. Khan's death is one point buried in the detail of this graph.
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Of course every death from EVD is tragic, a loss to general humanity and an event that is deeply painful for the family of the deceased. This consequence is independent of how famous, well known or important to others, the decedent is. In fact, most of those who died and are dying in this Ebola epidemic are "unknown" persons, men, women and children who may be known to a small circle of family and friends, but on the county level, have never been heard of... such as
the little boy in the media account that follows. He died of Ebola around the time Dr. Khan died.
In a remote village in rural Guinea, a 9-year-old boy arrived at a clinic with his sick moth-er. He was a little boy, 9 years old. He and his mother had both been infected with Ebola. She likely caught the virus while washing a deceased Ebola victim, as is often the custom for burials in Guinea. Then she probably infected her child.
Once she began showing symptoms, she and her son were locked in a house for four days because neighbors were so scared of the virus. Medical workers learned of the case. And the mother and son were driven to a treatment center in the back of a pickup truck, along a dirt road. The mother died on the way. So the boy was admitted, alone. He was cared for by foreigners, wearing outfits that look like spacesuits to protect them from the deadly virus.
Dr. William Fischer of the University of North Carolina tended to the boy. At the time, he was working in an isolation area in Gueckedou, Guinea, as a member of the Doctors Without Borders team that's treating people with Ebola.
The child came "with barely a pulse," Fischer recalls. In the isolation ward, health care workers resuscitated him, giving him fluids and antibiotics. A package of cookies coaxed a faint smile. "But he was in a tough spot," Fischer says.
Then the medical team had to leave the isolation zone. The equipment they wear, Fischer explains, offers protection for only a limited amount of time. They had "a sliver of hope" they could get him through this. That night, the boy began vomiting blood.
"He was by himself in this treatment center being cared for by people in these 'spacesuits' and it was one of the most difficult things for me to see. Not just the disease ... but the despair that was present," recalled Dr. William Fischer, who worked in Guinea for three weeks. "Just from being alone."
That night he died. Alone, no family, no one by his side. "You sit there and you tell yourself ... the chances of us being able to get him through this
are pretty low," Fischer says. "But man, it's miserable. It affects you. It feels like you're a fail-ure."
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Isata Kallon, a nurse at Kenema Hospital in eastern Sierra Leone, remembers the day 3-year old Ibrahim showed up at the Ebola treatment center. He was with his mother and two older brothers, ages 5 and 8. They all had Ebola. Ibrahim was especially sick, vomiting constantly.
"The chance of survival was very low for him," says Kallon, who's in her 30s. She sits at a
picnic table outside the Ebola ward, her hair pulled back with a hairband and her blue nursing scrubs tinged with sweat around the neck.
She spent much of the next week caring for the family, along with dozens of other patients in the makeshift Ebola ward -- a large white tent near a sloping hill outside the hospital. Each time she entered the unit, she would find Ibrahim in a different place.
"I often found him lying on the beds of other patients," she said. She wasn't sure if he was lonely or confused, but she had trouble keeping him in his own bed. "So every time, I had to take him, give him a bath and dress him up and put him back [on his own mattress]," she said.
Meanwhile, Ibrahim's mother's health began to worsen. She began vomiting heavily and had severe diarrhea. Then, roughly seven days after the family had first arrived, she passed away. Ibrahim and his brothers were still alive in their beds, just a few feet away. After their mother's body was incinerated, the boys began to recover.
Ibrahim, in particular, rebounded strongly. Two weeks later, they were declared Ebola-free and were discharged from the Ebola ward. They were temporarily moved to another build-ing within the hospital, where a group of roughly 30 Ebola survivors are living as they wait to go home.
The boys' father, who did not contract the disease, lives in a town called Port Loko, 170 miles away. He knows they are alive but has not been able to make the trip to bring them home, in part because public transportation across the country has been shut down or severely limited due to the Ebola outbreak.
So, in the meantime, the boys are being fed and looked after by other survivors -- includ-
ing parents who have lost children -- and the nurses, including Kallon. Perhaps because his mother is no longer around, 3-year-old Ibrahim has developed a strong attachment to Kallon. He comes to the nursing station frequently. She often has to send him back because she's busy.
To Kallon's surprise, Ibrahim made a very bold statement one day. "He said he wants me to be his wife," Kallon says, laughing.
Her response? "I accepted!" she says, smiling.
Now, Kallon says young Ibrahim waves to her whenever he sees her. "When I'm passing, he calls to me and he goes like this," she says, blowing a kiss into the air. The director of the hospital says Ibrahim and his brothers will soon be transported home, free of charge, because their father has been unable to retrieve them.
Kallon says she's happy the boys will be reunited with their father. But she admits that she and the other nurses will miss having them around. They lighten the mood in a workplace that often feels bleak. Ibrahim, in particular, is a ray of light, Kallon says. "I'm going to miss his pres-
ence, because he's my husband now."
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Six months into the epidemic, by June 2014, certain aspects of the epidemic were repeat-ed in media reports, usually with the implied but unspoken question of How could this possibly have happened? Where were the lookouts? Where is the cavalry?
1. Number of deaths so far, exceeded the total number of fatalities from all previous Ebo-la outbreaks combined.
2. This epidemic for the first time occurred in large cities, struck the capital cities of the involved countries.
3. This Ebola virus outbreak has ontinued to expand, rather than fade away as had previ-ous outbreaks.
4. The virus continued to take a disproportionate toll on the health professions, killing an unbelievable number of health care workers, doctors and nurses.
5. The resources made available for combatting the epidemic have clearly been inade-quate from the start. This fact was known to the entire world. Why did the world, WHO, others, not respond promptly, to save thousands of unnecessary deaths? What systematic problems lay at the heart of the unbelievable failure to respond on nation-al and international levels?
FFEEAARRSS
Through the summer of 2014, the epidemic spread further, the death toll seemed to climb out of sight, and the calls for assistance remained unanswered by "boots on the ground." As not-ed previously, these countries, especially Liberia, had been ravaged by a 14-year violent civil conflict, that ended in 2003. This conflict resulted in the near-total destruction of the country's entire infrastructure. Liberia's health services struggled to deliver basic services long before the Ebola outbreak. Hundreds of thousands of the displaced poor, died anonymous deaths in cities, towns and jungles.
Liberia had about 60 doctors before the Ebola outbreak. It's population was slightly great-er than 4 million. But by the middle of 2014 the Ebola virus had been killing health professionals preferentially. The Ebola related deaths of high profile and very competent medical professionals left the country's surviving health staffers demoralised.
The graphic below is dramatic. But it can't convey the real life situation. If you live in a Liberian town for instance, and you become ill for whatever reason, you have virtually no chance of hooking up with a medical professional and receiving standard care for your illness. For the most part you live and you die on your own time.
Hospitals, especially during the Ebola outbreak began to gain reputations as places to avoid.
"People are hesitant and fearful as they don't know what happens in a treatment unit and
have heard lots of negative stories," says Darin Portnoy, a medical doctor treating patients at a Medicines Sans Frontieres unit in Monrovia.
"That's where we lose the battle - when people hesitate to come in. We can't get on top of the disease when people turn up four, five days into their illness."
Liberia's health ministry has also urged people to stop burying their loved ones secretly at night. Even as knowledge of best practices to protect from the virus infiltrates the entire region, this will perhaps be the hardest thing to stamp out.
Rukshan Ratnam, a spokesman for Unicef in Liberia, said some families had hidden their sick to avoid sending them to isolation wards, or out of shame stemming from traditional beliefs that illness is a punishment for doing something wrong.
Dr. Haque said that the tracing of cases, crucial for the containment of the disease, was moving too slowly to keep up with new infections. Seven counties have confirmed cases, and the government has deployed security forces in Lofa County, where Liberia's first case was detected, he said. But the government has given leave to nonessential employees in those areas, so it is not clear how they will have the staffing to isolate the sick.
Some hospitals have closed because so many health workers have fallen ill. Liberia has closed markets and many border crossings. It has said testing and screening will be done at im-migration checkpoints.
But on Thursday, at a checkpoint staffed by at least 30 soldiers in Klay, Bomi County, there was no screening -- just a blockade and a line of trucks loaded with bags of charcoal, plan-tains and potato greens. Hilary Wesseh, a truck driver who was sucking the last drops of juice out of a small lime, said he had been stuck there for two days. "They are holding us hostage," he said.
The immensity of the Ebola Virus Disease (EVD) outbreak in West Africa has made some volunteer and humanitarian agencies decide to pull out of the "hot zone" countries of that area of Africa The Peace Corps announced Wednesday that it is temporarily removing its volunteers from Liberia, Sierra Leone and Guinea due to the increasing spread of the Ebola virus.
There are currently 102 volunteers in Guinea working in the areas of education, agricul-ture and health; and 108 volunteers in Liberia and 130 volunteers in Sierra Leone working in ed-ucation.
A determination on when volunteers can return will be made at a later date. In addition to the Peace Corps, Boone, NC based Christian International Relief organization, Samaritan’s Purse decided yesterday to curtail operations in Liberia due to instability and ongoing security issues in the area.
The agency does say essential medical staff are remaining on site to treat patients. On Wednesday, Samaritan’s Purse announced that two workers in the West African country of Li-beria who have been battling Ebola Virus Disease (EVD) infections, Dr. Kent Brantly and Nancy Writebol, have shown slight improvement in their battles with Ebola infection.
The World Health Organization Regional Office for Africa updated the Ebola case and death count yesterday. Between 24 and 27 July 2014, a total of 122 new cases as well as 57 deaths were reported from Liberia, Sierra Leone, Guinea and Nigeria.
The outbreak of Ebola virus disease in west Africa is unprecedented in many ways, in-cluding the high proportion of doctors, nurses, and other health care workers who have been in-fected. WHO reports that more than 240 health care workers have contracted Ebola infections in Guinea, Liberia, Nigeria, and Sierra Leone. Of these, more than 120 have died.
Ebola has taken the lives of prominent doctors in Sierra Leone and Liberia, depriving the-se countries not only of experienced and dedicated medical care but also of inspiring national heroes. Several factors help explain the high proportion of infected medical staff. These factors include shortages of personal protective equipment or its improper use, far too few medical staff for such a large outbreak, and the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe.
In the past, some Ebola outbreaks became visible only after transmission was amplified in a health care setting and doctors and nurses fell ill. However, once the Ebola virus was identified and proper protective measures were put in place, cases among medical staff dropped dramatical-ly.
Moreover, many of the most recent Ebola outbreaks have occurred in remote areas, in a part of Africa that is more familiar with this disease, and with chains of transmission that were easier to track and break. The current outbreak is different. Capital cities as well as remote rural areas are affected, vastly increasing opportunities for undiagnosed cases to have contact with hospital staff. Neither doctors nor the public are familiar with the disease. Intense fear rules en-tire villages and cities.
Several infectious diseases endemic in the region, like malaria, typhoid fever, and Lassa fever, mimic the initial symptoms of Ebola virus disease. Patients infected with these diseases will often need emergency care. Their doctors and nurses may see no reason to suspect Ebola and see no need to take protective measures.
Some documented infections have occurred when unprotected doctors rushed to aid a waiting patient who was visibly very ill. This is the first instinct of most doctors and nurses: aid the ailing. In many cases, medical staff are at risk because no protective equipment is available – not even gloves and face masks. Even in dedicated Ebola wards, personal protective equipment is often scarce or not being properly used.
Training in proper use in absolutely essential, as are strict procedures for infection preven-tion and control. In addition, personal protective equipment is hot and cumbersome, especially in a tropical climate, and this severely limits the time that doctors and nurses can work in an isola-tion ward. Some doctors work beyond their physical limits, trying to save lives in 12-hour shifts, every day of the week. Staff who are exhausted are more prone to make mistakes.
All personal protective equipment dispatched or approved by WHO meets the appropriate
international safety standards. The heavy toll on health care workers in this outbreak has a num-ber of consequences that further impede control efforts. It depletes one of the most vital assets during the control of any outbreak. WHO estimates that, in the three hardest-hit countries, only one to two doctors are available to treat 100,000 people, and these doctors are heavily concen-trated in urban areas.
It can lead to the closing of health facilities, especially when staff refuse to come to work, fearing for their lives. When hospitals close, other common and urgent medical needs, such as safe childbirth and treatment for malaria, are neglected. The fact that so many medical staff have developed the disease increases the level of anxiety: if doctors and nurses are getting infected, what chance does the general public have?
In some areas, hospitals are regarded as incubators of infection and are shunned by pa-tients with any kind of ailment, again reducing access to general health care. The loss of so many doctors and nurses has made it difficult for WHO to secure support from sufficient numbers of foreign medical staff. The African Union has launched an urgent initiative to recruit more health care workers from among its members.
Below, I'd like to review the chronology of "warnings" issued about the growing Ebola epidemic, and review the responses to this headsup. My interest is in learning why the warnings of impending catastrophe by informed organiszations and people, did not result in an effective response by those whose jobs were specifically to generate such responses, why governments looked the other way. The issue is not to pin guilt on someone for thousands of unnecessary deaths. They should all be fired of course. But the systematic defects that allowed this epidemic to reach the magnituted it did, and to kill as may people as it is, have to be delineated and then corrected.
Presently, this task requires an authoritative commission to investigate the WHO and oth-ers with totally free hand, to determine where and what went horribly wrong. Based on publicly available information, I haven't been able to approach the core of this problem. But I believe that if there had been just one knowledgeable person with the authority to unleash the cavalry, and they had been warned that Ebola was on the loose, the current tragedy would have been much less tragic.
In the future, when the word "Ebola" is whispered anywhere in central Africa, the global response should be a division sized influx of specialists to coordinate an immediate attack on the virus with the regional governments.
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The epidemic began in Guinea during December 2013. The World Health Organization (WHO) was officially notified of the rapidly evolving EVD outbreak on March 23, 2014. Re-ports suggest that someone, some committee in WHO decided this was not a big deal. Death be-gan to spread across west Africa.
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Facing the worst known outbreak of the Ebola virus, with almost 1,000 fatalities in West Africa, on August 8 the World Health Organization declared a Public Health Emergency of In-ternational Concern.
Dr. Margaret F. C. Chan, the director general of the World Health Organization, a United Nations agency, told a news conference at its Geneva headquarters, "This is the largest, most se-vere, most complex outbreak in the nearly four-decade history of the disease."
"I am declaring the current outbreak of the Ebola virus disease a public health emergency of international concern," she said. "Countries affected to date simply don't have the capacity to manage an outbreak on this scale on their own."
This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandem-ic and the 2014 resurgence of polio) which invokes legal measures on disease prevention, sur-veillance, control, and response, by 194 signatory countries.
WHO published a roadmap to guide and coordinate the international response to the out-break, aiming to stop ongoing Ebola transmission worldwide within 6–9 months. The organiza-tion stopped short of saying there should be general international travel or trade bans, but
acknowledged that the outbreak, already in its sixth month, was far from being contained.
Doctors Without Borders, responded to the statement with a renewed call for a "massive deployment" of health specialists to the stricken countries. "Lives are being lost because the re-sponse is too slow," it said.
There has been heavy criticism of the WHO from some aid agencies because its response has been perceived as slow and insufficient, especially during the early stage of the outbreak. This criticism from knowledgeable authorities continues despite this August declaration by WHO:
The W.H.O. urged all nations where the disease is spreading to declare an emergency, to screen all people leaving at international airports, seaports and land crossings, and to prevent travel by anyone suspected of having the Ebola virus. But the organization did not recommend a ban on travel to or from places with outbreaks because of the low risk of infection. "We don't be-lieve a general ban on that kind of travel makes any kind of sense at all," Dr. Fukuda said.
The declaration was apparently intended to display a more aggressive stance by the health organization. In the past, it has often bent to pressure from member countries, demanding that there be no consequences even as epidemics have raged inside their borders and sometimes slipped over them.
Above, people infected with Ebola virus, too weak to move, unable to be admitted to Ebola
unit. Many people simply lay where ever they could and alone though in public, died.
By mid-September, 9 months after the first case occurred, the numbers of reported cases and deaths were still growing from week to week despite multinational and multisectoral efforts to control the spread of infection. The epidemic has now become so large that the three most-affected countries -- Guinea, Liberia, and Sierra Leone -- face enormous challenges in imple-menting control measures to stop transmission and to provide clinical care for all persons with EVD.
Based on the response to WHO, and WHOs actual post declaration actions, knowledgea-
acknowledged that the outbreak, already in its sixth month, was far from being contained.
Doctors Without Borders, responded to the statement with a renewed call for a "massive deployment" of health specialists to the stricken countries. "Lives are being lost because the re-sponse is too slow," it said.
There has been heavy criticism of the WHO from some aid agencies because its response has been perceived as slow and insufficient, especially during the early stage of the outbreak. This criticism from knowledgeable authorities continues despite this August declaration by WHO:
The W.H.O. urged all nations where the disease is spreading to declare an emergency, to screen all people leaving at international airports, seaports and land crossings, and to prevent travel by anyone suspected of having the Ebola virus. But the organization did not recommend a ban on travel to or from places with outbreaks because of the low risk of infection. "We don't be-lieve a general ban on that kind of travel makes any kind of sense at all," Dr. Fukuda said.
The declaration was apparently intended to display a more aggressive stance by the health organization. In the past, it has often bent to pressure from member countries, demanding that there be no consequences even as epidemics have raged inside their borders and sometimes slipped over them.
Above, people infected with Ebola virus, too weak to move, unable to be admitted to Ebola
unit. Many people simply lay where ever they could and alone though in public, died.
By mid-September, 9 months after the first case occurred, the numbers of reported cases and deaths were still growing from week to week despite multinational and multisectoral efforts to control the spread of infection. The epidemic has now become so large that the three most-affected countries -- Guinea, Liberia, and Sierra Leone -- face enormous challenges in imple-menting control measures to stop transmission and to provide clinical care for all persons with EVD.
Based on the response to WHO, and WHOs actual post declaration actions, knowledgea-
ble health specialists remained critical of the international response.
"Declaring Ebola an international public health emergency shows how seriously W.H.O. is taking the current outbreak; but statements won't save lives," said Dr. Bart Janssens, the direc-tor of operations at Doctors Without Borders, which says it has hundreds of specialists in the field in West Africa. "It is clear the epidemic will not be contained without a massive deployment on the ground."
In my opinion WHO said all the right things, much later than it could have. But despite this, the relief in the field where the epidemic raged, didn't change. "A coordinated international response is deemed essential to stop and reverse the international spread of Ebola," the W.H.O. said.
The W.H.O. declaration on Ebola comes months after the outbreak was first identified in Guinea in March. Mr. Janssens said that a combination of factors -- including denials by the au-thorities in affected countries and the international community's slow recognition of the gravity of the crisis -- had all contributed to delays in gearing up an effective response.
Unlike previous outbreaks of the Ebola virus, which had occurred in isolated areas, the West African epidemic erupted in areas with more traffic, trade and freedom of movement, facil-itating transmission of the disease, he said. The affected countries also have extremely weak health infrastructures and lacked the capacity to respond effectively when the outbreak occurred.
"Between February and May it was always 'there's no problem,' " Dr. Janssens said of the reaction from the government authorities in the countries initially affected, "but during that peri-od the epidemic was spreading into many little communities away from the epicenter."
Liberia, which saw what had happened in Guinea and Sierra Leone, responded more quickly, but lacked the capacity to contain the disease and is now fighting the spread of the virus in the capital, Monrovia, he said.
The international response has also been weak, Dr. Janssens said, pointing out that Doc-tors Without Borders had previously called for a major escalation in international support and had warned that the epidemic was out of control. The W.H.O.'s regional officers, he said, "played a critical role in that failure in the first two to three months."
"They were in the same mode of denial as the governments were," he said.
In her comments, Dr. Chan said the W.H.O. was now "extremely stretched" in its capacity to deal with the epidemic. The organization has rotated more than 420 international staff mem-bers through the region since the start of the outbreak, and this week had 141 international staff members deployed, in addition to the people permanently based there, said Gregory Hartl, a spokesman.
"What we need there runs into the hundreds," Mr. Hartl said, noting that the W.H.O. ap-pealed last week for $100 million to support its response to the epidemic. Part of the challenge was finding people with relevant experience, for example in treating hemorrhagic fever. The or-ganization's statement called the spread of the disease an "extraordinary event," describing the potential consequences as "particularly serious."
The W.H.O. listed a series of worrisome factors in its spread, including "the virulence of the virus, the intensive community and health facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries."
In dealing with the Ebola crisis, the W.H.O. said Friday, stricken countries faced an array of challenges, with inexperienced personnel confronting "misperceptions" of the disease among highly mobile populations.
"A high number of infections have been identified among health care workers, highlight-ing inadequate infection control practices in many facilities," the statement said. But the body also said that the disease could be contained.
"This is not a mysterious disease," Dr. Fukuda said in a telephone briefing with journal-ists. "This is an infectious disease that can be contained. It is not a virus that is spread through the air."
Dr. Chan said she hoped that Friday's declaration would galvanize leaders of all countries to act. "It cannot be done by the ministries of health alone," she said. The European Union said on Friday that the risk to Europeans remained "extremely low."
The WHO's self-assessment, leaked to the public in October, concluded that WHO made
mistakes in dealing with the Ebola epidemic, they'd missed chances to stop the spread of the vi-rus and that the key factors contributing to it's malfeasance were: incompetent staff, a lack of in-formation, and bureaucracy due to 'politically motivated appointments'."
A WHO official spread the blame stating WHO knows mistakes have been made, but that "nearly everyone involved in the outbreak response failed to see some fairly plain writing on the wall". Of course it wasn't the job of nearly everyone involved to be looking for the writing on the wall and respond to it.
Dr. Peter Piot, co-discoverer of the Ebola virus, concurred with WHO's opinion of it's ca-pabilities, stating that the WHO staff is "really not competent."
AAUUGG 2299,, SSTTAATTEEMMEENNTT BBYY MMSSFF
Dead bodies in the street, families wiped out, dozens of health care workers infected, hospitals shut down and panic and mistrust in the eyes of the people in the streets. As of today more than 1,427 patients have succumbed to Ebola viral disease and the care centres established by Médecins Sans Frontières are overwhelmed.
The disaster is becoming even more dramatic as the health systems in the affected region have imploded. Patients are dying of Ebola, but also of malaria, diarrhoea or complicated deliv-eries due to the absence of effective medical care. In Liberia especially, hospitals are deserted. And fear is spreading.
MSF has been responding to the crisis since March 2014. We have opened up more and more isolation centres throughout the affected countries to care for the sick and we have assisted the communities. For the last three months, we have actively been calling for more hands-on as-sistance to control the epidemic and to provide the best possible care to patients.
However, the international response is slow and derisory. It can equally be defined as irresponsible. Today, only a handful of international actors are engaged in the fight against Ebo-la. But this is nowhere near enough. This is an exceptional crisis, the number of new infections is still on the rise, and the virus has a serious potential to spread to other countries. Promises of funding and political statements are not sufficient – decisive action is needed now.
SSEEPPTTEEMMBBEERR 33
By September 2014, Medicins Sans Frontires, the NGO with the largest working presence in the affected countries, had grown increasingly critical of the international response. Speaking on 3 September, the president of MSF spoke out concerning the lack of assistance from the Unit-ed Nations member countries saying, "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it."
CCOOAALLIITTIIOONN OOFF IINNAACCTTIIOONN
As the Ebola outbreak surges to record levels, the international response has been "lethal-ly inadequate" and has only worsened the epidemic by "marginalizing" the population affected, a chorus of top international medical officials said during a high-level United Nations briefing in New York on Tuesday.
Slamming the lack of response by UN Member States, Dr. Joanne Liu, international presi-dent of Médecins Sans Frontières (MSF) said that despite the World Health Organization's (WHO) announcement that the epidemic constituted a "public health emergency of international concern," outside countries "have essentially joined a global coalition of inaction."
"Six months into the worst Ebola epidemic in history, the world is losing the battle to con-tain it... In West Africa, cases and deaths continue to surge. Riots are breaking out. Isolation centers are overwhelmed. Health workers on the front lines are becoming infected and are dying in shocking numbers.
Others have fled in fear, leaving people without care for even the most common illnesses. Entire health systems have crumbled. Ebola treatment centers are reduced to places where peo-ple go to die alone, where little more than palliative care is offered. It is impossible to keep up with the sheer number of infected people pouring into facilities. In Sierra Leone, infectious bod-ies are rotting in the streets. Rather than building new Ebola care centers in Liberia, we are forced to build crematoria."
Accusing UN Member States of focusing "solely on measures to protect their own bor-ders," Liu added: "We cannot cut off the affected countries and hope this epidemic will simply
burn out. To put out this fire, we must run into the burning building."
On Tuesday, UN officials working on the ground in West Africa issued a separate state-ment saying that they "deplore the ongoing socio-economic consequences of the spread of the virus, including in particular the isolation of the affected countries with the risk of stigmatizing the populations." They added that the solution is "not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place."
MSF is calling for UN member states to deploy their federal biological threat and disaster response teams to the affected nations, "backed by the full weight of your logistical capabilities." They noted that international response must be done in "close collaboration" with the affected countries. The officials emphasized that the medical infrastructure in those places are now stretched beyond their limits and that workers have been dangerously exposed as a result. Since March, nearly a tenth of all Ebola deaths have been health workers, according to the latest statis-tics.
Medical staff at Liberia's largest hospital, the John F. Kennedy Medical Center in Monro-via, went on strike on Monday, saying they have been risking their lives without being provided with proper protection or equipment. "From the beginning of the Ebola outbreak we have not had any protective equipment to work with. As result, so many doctors got infected by the virus," a spokesman for the strikers told AFP.
Further, according to George Williams, secretary general of the Health Workers Associa-tion of Liberia, the medical staff at the JFK hospital had gone unpaid for two months. The strike follows a one-day protest at a hospital in Sierra Leone's capital Freetown on Monday and a simi-lar action at an Ebola clinic in eastern Sierra Leone last week.
LLAANNCCEETT SSEEPPTT 44
The Ebola crisis in west Africa could have been averted if governments and health agen-cies had acted on the recommendations of a 2011 World Health Organization (WHO) Commis-sion on global health emergencies, according to a new Comment, published in The Lancet.
The Comment, written by Professor Lawrence Gostin of Georgetown University, USA, calls for renewed international commitment to a health systems contingency fund to prevent an-other infectious disease crisis, together with long-term funding for enduring health systems de-velopment.
Although WHO has now implemented a plan for dealing with Ebola -- five months after the virus first began to spread internationally -- implementation will be further delayed while US$490 million are raised to meet the cost of tackling the epidemic. In the meantime, Ebola con-tinues to spread amongst health workers and the general population, in countries where health resources were already strained before the outbreak.
The 2011 WHO Review Committee proposed a Global Health Emergency Workforce, backed by a US$100 million contingency fund, which would have enabled the rapid initial re-sponse needed to contain the Ebola outbreak, but the Commission was not acted upon by WHO, lacking sufficient financial commitment from governments in high-income countries.
According to Professor Gostin: "How could this Ebola outbreak have been averted and what could states
and the international community do to prevent the next epidemic? The answer is not untested drugs, mass quarantines, or even humanitarian relief. If the real rea-sons the outbreak turned into a tragedy of these proportions are human resource shortages and fragile health systems, the solution is to fix these inherent structur-al deficiencies."
"A dedicated International Health Systems Fund at WHO would rebuild broken trust, with the returns of longer, healthier lives and economic development far exceeding the costs. This fund would encompass both emergency response ca-pabilities and enduring health-system development."
"The west African Ebola epidemic could spark a badly needed global course correction that would favour strong health infrastructure. Sustainable funding scalable to needs for enduring health systems is a wise and affordable in-vestment.
It is in all states' interests to contain health hazards that may eventually
travel to their shores. But beyond self-interest are the imperatives of health and social justice -- a humanitarian response that would work, now and for the fu-ture."
SSEEPPTT 1122
The current Ebola outbreak now requires a 'rapid response at a massive global scale,' ac-cording to experts. Writing an editorial in Science, Professor Peter Piot, co-discoverer of the vi-rus, says that the epidemic in West Africa is the result of a "perfect storm" involving dysfunc-tional health services, low trust in governments and Western medicine, denials about the virus's existence, and unhygienic burial practices.
The outbreak which began in December 2013 now spans five countries in West Africa and has so far killed nearly 2000 people, with the WHO predicting that 20,000 may become infected. Professor Piot, Director of the London School of Hygiene & Tropical Medicine, writes:
"This fast pace of Ebola's spread is a grim reminder that epidemics are a global threat and that the only way to get this virus under control is through a rapid response at a massive global scale -- much stronger than the current efforts."
According to Professor Piot, international assistance to the growing local efforts must in-clude support for disease-control activities such as the provision of protective equipment, patient care, and addressing the health, nutritional, and other needs of populations in quarantine.
It is also an opportune time to accelerate evaluation of experimental therapies and vac-cines. With the WHO announcing that compassionate use of experimental therapies is ethically justified, even if they have not been tested in humans, Professor Piot comments that "an excep-tional crisis requires an exceptional response."
The exponential growth in numbers makes tracing and surveillance for Ebola increasingly difficult, and that cases could double every fortnight if the situation remains the same.
"Fear and mistrust of health authorities has contributed to this problem, but increasingly it is also because isolation centres have reached capacity. As well as creating potential for fur-ther transmission, large numbers of untreated -- and therefore unreported -- cases make it diffi-cult to measure the true spread of infection, and hence to plan and allocate resources."
They also warn that it is not just Ebola patients who are affected by the outbreak. In cities like Monrovia in Liberia, the infection has led to the closure of most health facilities, and as a result, untreated injuries and illnesses have caused further loss of life.
In September, the United Nations Security Council declared the Ebola virus outbreak in West Africa "a threat to international peace and security" and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak; the WHO stated that the cost for combating the epidemic will be a minimum of $1 billion.
SSEEPPTTEEMMBBEERR 2266
In a 26 September statement, the WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."
The following texts report the epidemic more from the perspective of individual human beings caught in a mysterious, violent maelstrom not of their making.
Below, a series of emails sent to his family by UNC's Dr. William Fischer II who worked in an isolation area in Gueckedou, Guinea, since May 28, 2014, as part of a team from Doctors without Borders.
MMAAYY 2288,, 22001144
Two weeks ago everyone thought the Ebola outbreak was over and there was a problem with contact tracing (involving who would pay the people for tracking down contacts). As a re-sult, there are now multiple foci of Ebola outbreaks across the entire country and now into Sierra Leone. Gueckedou is likely the safest place to be as an isolation zone is already in place and a standardized system of caring for patients. More later. I love you all!! Billy
JJUUNNEE 11,, 22001144
Everyone, I'm sorry for the delay in correspondence - we are truly in the middle of the bush and water, electricity, and internet are extremely limited. There is quite a lot of despair in and around the Gueckedou. Unfortunately the epidemic shows no signs of slowing despite heroic efforts by both Doctors without Borders and WHO.
I'm typing as quick as I can right now as there are five new admissions and very little chance I'll get this off before I lose the connection. The continuing epidemic is really a result of significant distrust between the local population and treatment/epidemiology teams, as well as, the non-specific nature of the symptoms.
Hemorrhagic complications occur only 50-60% of the time and many of them are mild (bloody diarrhea and hematemesis). It is different than what the movies and books have project-ed although I suspect that early descriptions came from end stage cases that received little care.
The isolation zone/treatment center really serves two purposes - to isolate patients in an attempt to stop the train of transmission and to provide what little care we can. As you can imag-ine we have limited resources for treatment. My role has really been to try to provide critical care clinical guidance to see if we can improve our mortality rate but to be honest we are truly limited by the personal protection equipment (PPE).
The PPE consists of scrubs, a pair of gloves and large rubber books both covered by an impermeable tyvec suit then covered by an impermeable full-length apron. A mask covers your mouth, goggles cover your eyes and an impermeable hood covers your head so that there is not a single inch of skin exposed. This is all in 30 C [86F] heat with >90% humidity.
I am now starting to acclimate after 3 days with 2 tours in the isolation zone. I had my doubts on the first day. This experience does offer an important perspective on critical care in that one of the most important aspects of what I am able to do at UNC is reassess and adjust my therapy whereas here I have to assess, make a decision, run outside, yell for fluids to be pre-pared, which are thrown to me, then run inside and set up the IV.
Then do it again for the 14 other patients currently in isolation. I'm not sure that I can augment care without the ability to reassess. I had hoped that improving the care of patients might allow us to find some life amongst all of this death but I'm not sure if it will work out that way.
My day starts with rounds at 7:30 a.m. and I usually have to call for another car as the last truck has usually left by the time I'm out of the isolation zone (around 9-10 p.m.) and head back to the hotel. Fantou Rose experienced its peak as a hotel a LONG time ago.
Now it's a shell of its former self without water or electricity but there is a mini fridge and a TV in the room, neither of which work nor look like they ever worked. But there is nothing quite like a bucket shower after losing 8 liters of sweat in a day.
The hardest part is not being able to talk with Leah and the boys, who I miss dearly. I love you all and will call soon. Best, Billy
JJUUNNEE 22,, 22001144
Today was a pretty tough day - one of the first two patients I admitted on May 30 died. I walked into his room and he was on the floor half naked surrounded by bloody emesis and diar-rhea. I put him back in bed, bathed him, and put fresh clothes on him and as I finished he died.
It's pretty emotional to bathe a 27-year- old man who was incredibly strong and rendered completely helpless. His sister is next door and will likely die in the next hour. This is all in front of the other patients in the room, many of whom are family members or neighbors. The despair is suffocating. My computer is running out of batteries. Sorry, more to come. Love y'all, B
JJUUNNEE 33,, 22001144
Each day has its bright and dark moments. There are two people in the "treatment center" that are improving. One is a young man who has started helping us encourage the other people in his room to drink more and to keep fighting. It is inspiring to say the least. The other is an older man who claims to be 35 but is more likely 85 and every time I walk into his room he acts like he is doing calisthenics - it provides a moment of levity against all of the struggle that defines the isolation zone.
Unfortunately we also have an 18-year-old woman who is 5 months pregnant, has Ebola, and malaria. I thought being 18 was tough - I can only imagine being pregnant, infected with a near uniformly fatal virus, having malaria, and being in an isolation zone treated with people in space suits.
The clinical course of pregnant w oman with Ebola is not good, to say the least, and unfor-tunately she began having contractions overnight and we "helped" her deliver a non-viable fetus this morning. Miserable.
Fortunately we found some oxytocin in the village and were able to give it to her but she has had significant hemorrhage. There is no blood to be given and no family has shown up who could potentially donate. I've been trying to resuscitate her with Lactated Ringer's but it feels like I'm trying to put out a fire with squirt gun.
Relations with MSF are excellent and we, along with 3 local physicians, are working well together and supporting each other. The one or two patients who are showing signs of life moti-vate me (us) to continue to push for every inch. I'm hoping that we can discharge the older gen-tleman today as a cure which would be great for him, us, and the rest of the patients!!
Yesterday, I went into the isolation zone carrying a small thermometer in my pocket to measure the temperature in my suit - 46 C or about 115F. We spend between 1-2 hours in there at a time, typically, 2-3 times per day.
You lose all sense of time once you're inside, but have to pay very close attention to your breathing and heart rate and head out when they start to increase, as it takes 10 minutes to actual-ly get out. Today there is a big meeting between the Gueckedou team and teams from Liberia and Sierra Leone.
In addition to losing my sense of time, I have no idea how the epidemic as a whole is do-ing because I'm so focused on the clinical work. At night I try to get updates from the WHO epi-demiologists and it all sounds very discouraging. Each day there is a new report of 10-15 deaths in a particular village. It is pretty amazing, however, to link the patients and risk factors together in an attempt to understand and stop transmission.
What else can I tell you other than I'm happy, healthy, miss my boys and Leah. I do wor-ry about how to transition back to academic life and how to build upon this experience. Love y'all, Billy
JJUUNNEE 44,, 22001144
Part of what makes Ebola so devastating in addition to the manner in which people die, is that this virus wipes out families. It penalizes those families who are close and transforms tradi-tion into transmission. The 18- year-old pregnant woman that I wrote about yesterday died. After delivering she continued to hemorrhage despite oxytocin and uterine massage.
When her husband was told about this he responded with, "ma vie est fini" ("my life is over"). Ebola has killed his mother, his mother-in-law, his wife and their unborn child. I worry that when the fight leaves a person the body is quick to follow. Similarly, when a woman died last week, her mother, who was also a patient and improving, soon followed. I'm not sure that there is anything worse than dying with despair after watching your child die.
Despite all this suffering there are moments of hope. There is one older man, who, as soon as I walk in, starts doing calisthenics to demonstrate his clinical improvement. I can't help but smile and he has started doing them when he sits outside and we walk by - he is the first person I look for when I arrive at the isolation center. Another younger man has started to do well and I anointed him team leader for his room. He has embraced this role brilliantly by helping the other patients in this room encouraging them to drink and helping to translate Kissi into French for me.
People in Gueckedou are incredibly kind and seem so happy though it is hard to think that life is fair given the juxtaposition of excess in the developed world and need in resource-
constrained environments. Despite this inequality, we are treated so well by our hosts and by the patients and that kindness is incredibly motivating.
My role as a physician has also changed importantly. Here, in addition to treatment plans, I clean, bathe, feed, change IV lines, and teach. Clearly, I'm more proud of the comfort I provide than the treatment that I lack but I'm more hopeful today than yesterday that critical care man-agement will save some. Love you all!! Billy
JJUUNNEE 77,, 22001144
The MSF operation is impressive. It's composed of many different subgroups including physicians, nurses, staff who clean the personal protection equipment and scrubs, hygienists who direct the PPE removal, the European lab group, epidemiologists, anthropologists, contact trac-ers, community outreach/educators, and others.
Each one has a different coping mechanism to deal with the duress of this work. The phy-sicians argue about when to retest those that are doing well because once they are symptom-free for 3 days and have two consecutive negative tests separated by 48 hours they can be discharged as cured. The hygienists listen to music although this week they've been on a Celine Dione kick which requires its own coping strategy.
However the Euro lab strategy is the most amusing - they want to test the Ebola chicken. Although the isolation zone is designed to separate those who are suspected of infection, those who have confirmed Ebola, and health care providers, it is practically impossible to keep the free range chickens from running where they want.
There is also a rabbit that pops out around the suspect tent every day. It's a bit concerning from an infection prevention and control perspective that these chickens can get in and out of the isolation zone - it brings up the constant concern for transmission of Ebola and the perceived need for such intense personal protection equipment.
The Ebola virus has been isolated from almost every body fluid including sweat, semen, blood, urine, oral secretions and tears. As I mentioned yesterday, this virus has transformed tradi-tion into transmission. Many of the people who test positive have participated in the funeral of a loved one which involves intimate interaction with a body including touching and cleaning the body, and even eating in the same room as the body.
Unfortunately, patients with Ebola continue to secrete body fluids after death. So much so, that in the Gulu outbreak (Uganda) they had to wrap the bodies in rugs to absorb the fluids that were released. This virus thus transforms a cultural experience that brings people together into a foci of transmission facilitating spread of the virus to many more people and their families when they return home.
Even before death, though, when people become ill, they are cared for by their loved ones as any and all of us do. When was the last time you wore gloves, eye protection, and an N-95 when your son or daughter had diarrhea?
Infected pregnant women create an especially volatile situation as they are often assessed weekly or monthly by midwives who rarely have the necessary protective equipment. The infect-ed midwife spreads the virus to the women she sees clinically. Unfortunately, there has never been a report of a pregnant woman who has survived and our experience in Gueckedou is no dif-ferent. To make matters worse we admitted a symptomatic midwife who has been working the past week and has now tested positive. In a cruel twist the very centers that promise to provide and protect become those that transmit.
The potential for hospital-acquired transmission coupled with the incredibly high mortali-ty rate of Ebola (and especially the Zaire strain which is the one we are battling here) leads to significant distrust between the community and the treatment center. They see us taking their family members with nonspecific symptoms (fever, diarrhea, vomiting) and returning them in a sealed body bag and robbed of their ability to say goodbye as their culture deems appropriate.
Rumors claiming the white people brought Ebola certainly don't help but I also can't blame them as the times that we truly intervene are during moments of crisis. This becomes a circular problem as the later the patients present, the more difficult it is to resuscitate them and the higher the death rate which leads to more distrust, more hiding and more death. The most powerful therapy for this is to save a life and to bring them back to their community.
This is called a "sortie guerit" or discharge cure. Yesterday, we had two and it was pretty emotional - the entire physician and nursing team were clapping and yelling as these two men
walked out. Today we have another potential and I'm waiting for her test now. A truck has just rolled up with a pretty sick woman and child, will write more later. Love you all! Billy
JJUUNNEE 88,, 22001144
As the reality of my departure nears I can't help but feel some sense of guilt--guilt for not having done more, faster, and better. But I think this feeling emanates from the fact that I can leave and the patients in this epidemic can't.
Last night we admitted a young boy who was transported with his mother from Kueldou. They had been locked in a house for four days because they were symptomatic. Unfortunately the delay in presentation was significant as only the boy was admitted because his mother died in transit. The 9-year-old boy sat next to his mother as she died. Now he sits in the isolation ward alone.
His father and brothers walked the 25km today to the isolation ward as the family's village has rejected them and reported that the father may have symptoms. The MSF team sent a car to pick them up but the father refused to ride given what happened to his wife. Fortunately, the 3 other siblings do not have symptoms but I'm concerned it's only a matter of time as the father walked 25km with one of the children tied to his back exposing him to potentially infectious sweat.
The estimated 21-day incubation period of Ebola complicates contact tracing given that people can theoretically be symptom free for 3 weeks following exposure. Since we can't hold the family in the isolation ward for 3 weeks we can only test them now and formulate plans to follow them in case they do develop symptoms.
When the 9-year-old was brought into the treatment facility he barely had a palpable pulse. When I met him he was weak, in pain, but incredibly stoic and most awfully alone. With fluid resuscitation we were able to get a pressure and with that a chance. His clothes were soiled and so we brought a new outfit for him. After some effort I got him to smile and in that smile I found false hope.
With Ebola you can't have a good death. You are isolated from your friends, your family, your home. You are cared for by people whose primary focus is on stopping transmission from infected to susceptible and from patient to provider rather than comfort and cure. These people often die without the comfort of a human hand, without seeing someone's full face or even just knowing that a loved one is near. I think of all the death notes that I've written in the United States and the bulk of them usually include the sentence, "they passed away peacefully with family at the bedside."
I didn't get a chance to write that for this little boy. Despite the hope that his smile brought me, he died overnight. In the void of darkness he converted to hemorrhagic shock with massive vomiting of blood and I'm told he bled out on the floor of the isolation ward. I can't help but think about what his last days were like – being locked in a house with his mother by his family and his community out of fear; then watching his mother die in the back of a pick up truck, being placed in an isolation zone staffed by foreigners in space suits, and finally vomiting blood alone.
I am troubled that I'm not better at this - that I haven't figured out a way to implement more advanced healthcare infrastructure that would allow us to save more. When this epidemic is over I am sure there will be more time for reflection but now there are more patients and more chances to help. Miss and love y'all Billy
JJUUNNEE 1100,, 22001144
I've just made the 2-hour trip by truck from Gueckedou to the dirt runway of Kissidougou and I'm trying to process all that has happened over the past three weeks. I'm told this is the first time that WHO has specifically sent critical care clinicians into the field to try to help improve the clinical care of critically ill patients.
They have sent countless physicians into the field as epidemiologists, anthropologists, and Dr. Fischer in the village of Kissdougou. infection control and prevention experts who have done amazing work to provide care and stop disease transmission but sending critical care specialists is somewhat new.
Ultimately, I think that this has demonstrated real promise and I think we've also learned a couple of things:
1. Ebola-related mortality can be reduced immediately with early, aggressive critical care
management. While vaccines and specific antivirals would be extraordinarily helpful, the majori-ty of patients are presenting with low blood pressure and shock that is responsive to aggressive fluid resuscitation.
I believe the key however, is not just in the recognition of shock and institution of early aggressive fluid resuscitation, but also in the constant reassessment and modification of therapy as needed which is a defining feature of intensive care medicine.
Additionally, while vaccines and Ebola-specific antivirals are years away, aggressive sup-portive care is possible now. Improved mortality rates from augmented clinical care will result in enhanced trust between patients and providers and ultimately earlier recognition of those that are sick and decrease transmission.
2. The fear of Ebola is almost as dangerous as the virus itself. I truly believe this is a sig-nificant barrier to improving the clinical care of patients infected with Ebola. The most difficult part of this mission for me was the week prior to leaving Geneva for Guinea.
I was consumed with how this virus is portrayed (90% mortality, bleeding from every ori-fice, decimated villages, etc.) rather than what we know about this virus (it is caused by a virus that is readily transmissible, has hemorrhagic complications of varying degrees in 50-60% of the time, and is potentially survivable with aggressive clinical care).
Fear is incredibly inhibiting to both healthcare provider recruitment and with contact trac-ing – two critical pieces in the struggle to control an outbreak. Patients fear the isolation zone because their experience has been one sided: friends and family members go in with common symptoms of diarrhea and vomiting and leave in a body bag with absolute restrictions on touch-ing the body.
Additionally, trying to recruit physicians to come to a resource-limited environment to fight a virus that is synonymous with death has been difficult, to say the least. But the data on transmission and our experience with this virus tells us that transmission can be interrupted with effective infection control interventions.
I look back at my own recruitment and remember a conversation that I had with Rob Fowler in which I said, "if you don't get me on that plane soon I'm going to think my way out of this." It was mentally exhausting worrying about my ability to contribute, my own safety, and the effect this mission would have on my family. In hindsight, getting on that plane was both incred-ibly difficult and one of the best decisions I've made professionally.
Destigmatizing this infection is just as crucial as providing intensive clinical support as both will lead to patients presenting earlier in their illness and increased numbers of healthcare workers to assess and reassess patients.
3. There is an incredible strength in the combination of structure and flexibility. Healthcare organizations are not only capable of working together but it is abundantly clear that we are stronger together than apart. MSF and WHO are incredibly capable organizations that separately provide great work but together they can be both synergistic and heroic.
Without the structure of MSF, I would not have been able to solely focus on patient care, and without WHO, MSF would continue to provide great clinical care but hopefully will benefit from subspecialty expertise. There remains; however, a tremendous need for organizational and regional coordination to ensure this crucial synergy.
The location of this outbreak has profound geopolitical implications and as a result I'm concerned that this epidemic is far from over. I'm leaving with both hope that critical care sup-port can improve outcomes of Ebola infection and some sadness that I'm leaving before the end of the epidemic. Miss and love you all, Billy
It's hard to imagine it now, when the death toll from Ebola is in the thousands. But just a few months ago, you could count the victims one at a time. For Dr. Joshua Mugele, the counting began one morning in June when he showed up for work at the John F. Kennedy Memorial Hos-pital in Monrovia, Liberia. Mugele, an ER doc and associate professor of clinical emergency medicine at Indiana University School of Medicine, was on a fellowship, working with staff to develop disaster readiness programs. The project had nothing to do with Ebola.
On that particular morning, Mugele showed up at the hospital to find a colleague in the parking lot, nervously making phone calls. When the man saw Mugele he told him the news:
"We have a patient with Ebola."
One of Mugele's first questions was whether the patient was in isolation. He was told the Ebola victim was in the same crowded emergency department where he'd been all night. Mugele raced to the emergency department and paused at the door. Small and crowded with no ventila-tion or air conditioning, the room always had a horrible stench; today was no exception. As he stood there, a colleague pointed to the back of the room. There he was -- you couldn't miss him.
"He was lying on an iron bed at the far end of the emergency department, obviously sick," Mugele remembers. "He's sweating. He's moaning. He's essentially comatose."
Two doctors joined Mugele in the doorway: Samuel Brisbane, one of the hospital's senior physicians, and Abraham Borbor, head of medicine in the emergency department. This was a moment they'd all been dreading. For weeks, Ebola had been at the forefront of their thinking as the epidemic seemed to pick up steam. Mugele says they'd talked a lot about the virus and how scared they were about what might happen if a patient with the disease turned up.
Brisbane, 74, was especially worried because he knew from past experience treating other viral hemorrhagic fevers just how dangerous these types of viruses could be. He was so worried he carried around a thermometer to take his own temperature on a regular basis, just in case he'd been exposed to the disease without knowing it.
Now all that worry would have to turn into action. It took the three of them a few minutes to figure out what to do. "We knew we needed to get him into an isolation room," Mugele says, "and we were trying to decide if the room had to have a sink or a working toilet. Or can you use plumbing with Ebola, or do you have to actually burn the feces? We just were trying to remem-ber exactly what had to be done."
In the end, they decided the most important thing was to move the man into an isolated room with its own trash can. Not a lot to ask for, and yet there just weren't any empty rooms to spare; a small enclosed area at the back of the emergency department would have to do. They began gowning up. Mugele says everyone was nervous, yet they were joking around. At one point, he reached for a pair of gloves and grabbed for a gown when Borbor stopped him.
"He laughed at me and said there's no way you're going to be touching this patient. He said, 'I'm not going to make the international news for letting the first white man catch Ebola.' "
Mugele didn't want to pull back. But he felt that as a guest at the hospital, he had to re-spect Borbor's demand. Mugele turned to help two custodians who'd been called in to move the patient -- men in their late teens or early 20s. They clearly had no idea how to put on protective gear: "I doubt they'd ever put on latex gloves before."
Mugele demonstrated how to put a gown and mask on properly and how to put on not one but two pairs of gloves. "They were very nervous, obviously; they were terrified," he says.
Once gowned up, the two young men and Borbor grabbed hold of the iron bed the patient was lying on and tried to move it through the doorway and into the isolation area. The bed wedged in the doorway. They yanked the bed out and decided to carry the patient on the mat-tress.
But there was a problem, Mugele says: "There's one person on one side of the mattress and two on the other, so they have a difficult time navigating around the iron bed and almost drop the mattress. And so Dr. Brisbane, who's sitting next to me and who hasn't gowned up, grabs a pair of gloves and puts them on and grabs the mattress and holds it up."
Between the four of them, they were able to navigate the patient and his mattress around the iron bed. They needed to take a break, so they put the patient and mattress down. They then shoved the mattress through the doorway as much as they could and climbed over it, "pulling it the rest of the way into the small isolation room," says Mugele.
"It's terrifying watching it." It was equally terrifying for the custodians and for Brisbane, who came perilously close to an Ebola patient with no protective equipment except a pair of gloves.
"The patient is septic, so he's covered in sweat," Mugele says. "And these guys are now all in this hot little room, and they're covered in sweat. Dr. Borbor's mask actually slips down over his mouth at one point." Mugele reached over to adjust the mask, but Borbor snapped at him:
"Get Brisbane to do it; he's already touched the patient." It was a mess. The patient was having difficulty breathing, so Borbor crouched by the man
and tried to keep his tongue from closing off his throat. While this was going on, Mugele noticed that, to his horror, the custodians were leaving the isolation room. "And I'm yelling at them, 'Stop! Don't move. Don't come out of that room. Don't touch the walls.' "
At about that time, the patient, who had been holding on since midnight the night before, died. The custodians and the two doctors removed their gear and left, holding their hands up so as not to touch anything. They headed for a sink and spent the next 10 minutes washing "and re-ally trying to decontaminate as best they can."
Unfortunately, their best was not good enough. Mugele returned to Indiana a week later; a few days had passed when he received a call from an acquaintance in Monrovia. Dr. Samuel Brisbane had contracted Ebola and was being cared for at a government treatment center.
Brisbane died a few days later. So did Borbor, the man who just might have saved Mugele's life by preventing him from getting close to the patient.
SSIIEERRRRAA LLEEOONNEE,, JJUUNNEE 1155 [[NPR's Jason Beaubien]
Today Jason is in Kailahun, the largest town in Sierra Leone's eastern province, with a population of about 18,000, and the epicenter of Sierra Leone's outbreak. In the past week, Doc-tors Without Borders staff in Kailahun have treated more than 70 patients with Ebola-like symp-toms. When we called, Beaubien was with a team driving to the treatment center to pick up the body of a 70-year-old woman who died of Ebola. Burial was scheduled for this afternoon.
The Ministry of Health is handing over body management to the Red Cross. This is one of the first bodies they're going out to do, so there's a whole bunch of people [who will be at the burial]. It may turn into a bit of a mob scene. And there's a lot of anger in the community; there's a potential that family members might not be happy that such a large group of people are show-ing up at the burial.
WWhhaatt''ss ffuueelliinngg tthhaatt aannggeerr??
There's been a lot of frustration and lack of understanding among the community about the need to not touch the body. Traditional burial would include washing the body by hand. So there's been some tension when the health teams come in telling people they're not allowed to touch the body, and that the body has to be zipped up in a body bag and disposed of by people in hazmat suits.
They've shut down the schools, and the government has issued an order saying that people who harbor people with Ebola and don't bring them for medical treatment will face criminal charges. A lot of people early on didn't necessarily accept that this was some new disease. They figured it was malaria or Lassa fever or something like that. That's part of what has led to some of the resistance and misunderstanding -- people not knowing that this virus is different.
People have been told not to shake hands. But this is West Africa. People usually grab your hand in both their hands and don't let go, especially someone who really wants to engage with you. It's very hard for people not to shake hands. You go into an office, and people have their hands in their pockets just to keep from pulling them out and shaking hands.
As much as you know scientifically about how it's spread and what you have to do to come in contact with it, it is still quite scary to know there is a virus floating around that's got a better than 50 percent chance of killing you. Just driving through the forest, I was thinking that somewhere out there, there's some [animal] host that has this virus coursing through its body, waiting to jump into humans. No one has proven definitively that [that's the source of the virus], but it seems like it's that. So it's a little ominous to look into that jungle and think about that.
People are hiding from health care workers. New cases are turning up in unexpected places. At funerals, family members don't always follow the advice not to touch the body of the deceased, which may still harbor the deadly virus.
These are a few of the signs that, in the words of public health specialist Armand Sprecher of Doctors Without Borders, the Ebola outbreak that began in West Africa in February is "not under control yet."
The first cases were in Guinea, but the virus has since spread to Sierra Leone and Liberia. The death toll has risen to 330, making this the deadliest Ebola outbreak since the disease was first detected in 1976. The staff of Doctors Without Borders is "overwhelmed" by the need to set up new isolation wards and track down people who may be infected, Sprecher told NPR's Jason Beaubien.
In past outbreaks, there have been what are called "satellite cases," where the disease ap-pears in different locations. But "not nearly as many as we've seen in this outbreak," says Sprecher. That may be because people move around a lot in West Africa.
"More manpower would certainly help," Sprecher says. "We are spread thin."
When a new case is reported, medical staff tries to visit everyone that person has had con-tact with. The villages that workers must go to may be many miles from each other. In addition, Doctors Without Borders has had to launch operations in two additional countries, building isola-tion units in Sierra Leone and Liberia as well as in new locations in Guinea. But the health care workers don't use the word "isolation."
"It carries a negative connotation," Sprecher says. "Family members care for each other in this part of the world. It's better to say that an Ebola patient will be taken to "a place where they can be cared for safely." A patient who is well enough may sit in a chair outside and chat with family and friends who are gathered outside a fence surrounding the treatment facility.
The reaction of locals makes it harder for medical workers to do their job. If someone is running a fever and has had previous contact with an Ebola victim, medical workers want to bring that individual to a "treatment unit" to be tested, Sprecher says. But people seek to conceal their illness because of the stigma of Ebola: "They don't want us to know; they don't want their neighbors to know."
So the person who has a fever will not step forward. Even when a medical worker knocks on the door trying to find anyone who's had contact with an Ebola victim, "people hide."
Previous Ebola outbreaks have been controlled with a matter of weeks or months. That's partly because victims die so quickly, sometimes just days after the virus sets in. And when the outbreak is confined to a relatively small area, quarantines are easier to enforce. This time around, says Sprecher, the fear is that the outbreak will become "a regional health issue" that will not go away.
TTHHEE OOVVEERRHHAAPPPPYY SSUURRVVIIVVOORR,, JJUULLYY 1188 [NPR's Jason Beaubien:]
Today I was following around MSF [Doctors Without Borders]. They're training volun-teers to explain to the community what causes Ebola, what the symptoms are, how to protect yourself. We're in this meeting with probably three dozen people, and this guy walks in. He is the former health officer from the region called Koindu, which sits right up against the [Guinea] border.
And he got Ebola. He had just gotten out of the treatment center this week. He walked in to this hero's welcome; everyone started cheering and clapping. It was like he was taking the stage in The Price Is Right. He came running up to the front of the room, declaring that he's free [of Ebola] and that he survived. It was this incredibly joyful moment.
He's Saidu Kanneh, and he's about 40 years old. He just had this spring in his step, this in-credible smile across his face. He was full of energy. He was planning to spread the word that you can survive this. He refers to himself as "overhappy."
He was one of the first medical workers dealing with cases. He said he was working with this woman who had Ebola. He was wearing rubber gloves, but there was a gap between the
gloves and his shirt. He believes that's how it happened.
HHooww lloonngg wwaass hhee ii ll ll??
He spent 12 days in the treatment center in Kailahun and got out this week, completely cured. MSF people tell me no virus could be detected in him anymore.
I talked to him across the fence [separating the isolation area]. He was saying he was in-credibly bored inside. He would come and sit by the fence and listen to his radio. He was eager to get out.
Supposedly people are able to do that. But we didn't see any family members interacting with patients while we were there. That's not to say [such interactions] are not going on. But people are quite nervous about coming to the treatment center.
The MSF people say getting people in early [for treatment] gives them about a 10 percent better chance of surviving. You basically treat it like influenza. You rehydrate patients. If people have a fever, you knock it down with Tylenol.
If doctors told him to drink 4 liters [1.1 gallons] a day of water, he drank 10 liters [2.6 gal-lons]. For him, it was just focus, focus, focus on recovery.
Ebola is not quite as scary as it seemed when I first got here. It's not like everybody here has Ebola. There are a couple hundred cases in this part of Sierra Leone -- a district with half a million people. That's not to downplay the problem. But being here has made me realize that Ebola is not as "in your face" as you think it'd be. And it's quite clear that this can be contained.
Everybody seems to feel this is going to go on for months -- if we're lucky -- rather than years. People are hoping to get over the hump and see numbers go down. The turning point has not been reached. But the elements are coming together that could wipe this outbreak out.
In normal circumstances, extended families would take in orphaned children but many are now refusing to do so, they say. "Children are sent off to extended family outside affected areas, but extended families don't want to take care of orphans of affected parents or other vul-nerable children any more out of fear of being contaminated or stigmatised in the community," said Dr. Unni Krishnan, head of disaster preparedness and response for Plan International.
John, five, from Lofa County, Liberia lost both his parents to Ebola. When they died, no--one was prepared to look after him and his sisters because their parents had died from Ebola. Their extended family is from Sierra Leone but it has not been possible to trace them.
Siah, 16, is the oldest of three siblings and is now facing the challenge of raising her younger brother and sister. "We cry every day and night because of Mama," she says. "I can't imagine how I will take care of the children without any help. I feel very scared right now. I don't want Ebola to catch any other member of my family. I can't afford to lose any of these chil-dren to Ebola."
In Bomi, Liberia, Miatta, 16, Jenneh, 12, Musa, five, Larmie, one, and Hawa, six months, are the only remaining members of their family. They lost both parents to Ebola. Miatta is now raising her brother and two sisters along with her son Larmie. "When my mother was sick, they came for her," she says. "I was scared and thought they were spirits because of the clothes they were wearing."
"When day breaks, I cook dry rice, and we eat," says Miatta. She says the health ministry gave them 30 cups of rice when their mother died, but they have not received any more food from the government. "I want to be a president in the future," she adds. "When I become presi-dent, I will make sure that things will become accessible like rice and medicine."
Musa and his siblings are sometimes given food by churches or community members. They are trying to keep themselves safe by washing their hands regularly, but they have little money, which they need to buy chlorine for the water. Also in Bomi, Pascaline, 14, Noami, 12, Yonger, 11, and Blessing, two, sit on the porch of their home on the first day the quarantine was lifted from their house after they lost their parents to Ebola.
Their elder sister Fatu, 28, says their father was the first to get sick from Ebola. "He used to work at the Ahmadiya hospital. He was treated but he didn't recover and he died. After a few days, grandma also got sick and died. Our mother also died after 14 days and then the last to die in this roll was my little brother."
Fatu says: "I'm feeling bad for several reasons. I have not been able to go to the hospital for my regular check--up as a pregnant woman because of the 21 days quarantine that was placed on their house. Also, people in the community are stigmatizing us because they say Ebola is in our house. So nobody wants to have anything to do with us."
As a result of my time in Liberia, I encountered the exceptional images taken by John Moore, a, a photographer for Getty Images who came to Monrovia this August after convincing his bosses that the worsening Ebola situation in Liberia was a worthy subject for documentation.
Moore documented the relief efforts, the people afllicted with Ebola, the confusions and conflicts that have arisen in the course of the epidemic, with exceptional skill. A person requires a deep sense of dedication, a clear sense of the value of his work, to go into situations such as Moore did, and take the photographs he did.
He's one of that small group of global archivists, people who I think of as documenters sent by a higher power, people who have entered into the cauldron in order to gift humanity a true record, a historical archive of great value, depicting with raw honesty lives lived on the edge of catastrophe.
[Above: by John Moore: A burial team from the Liberian health department sprays disin-fectant over the body of a woman suspected of dying EVD on Aug. 14, 2014 in Monrovia.]
In one corner of Liberia, a community has come together to change the course of the dead-
"When day breaks, I cook dry rice, and we eat," says Miatta. She says the health ministry gave them 30 cups of rice when their mother died, but they have not received any more food from the government. "I want to be a president in the future," she adds. "When I become presi-dent, I will make sure that things will become accessible like rice and medicine."
Musa and his siblings are sometimes given food by churches or community members. They are trying to keep themselves safe by washing their hands regularly, but they have little money, which they need to buy chlorine for the water. Also in Bomi, Pascaline, 14, Noami, 12, Yonger, 11, and Blessing, two, sit on the porch of their home on the first day the quarantine was lifted from their house after they lost their parents to Ebola.
Their elder sister Fatu, 28, says their father was the first to get sick from Ebola. "He used to work at the Ahmadiya hospital. He was treated but he didn't recover and he died. After a few days, grandma also got sick and died. Our mother also died after 14 days and then the last to die in this roll was my little brother."
Fatu says: "I'm feeling bad for several reasons. I have not been able to go to the hospital for my regular check--up as a pregnant woman because of the 21 days quarantine that was placed on their house. Also, people in the community are stigmatizing us because they say Ebola is in our house. So nobody wants to have anything to do with us."
As a result of my time in Liberia, I encountered the exceptional images taken by John Moore, a, a photographer for Getty Images who came to Monrovia this August after convincing his bosses that the worsening Ebola situation in Liberia was a worthy subject for documentation.
Moore documented the relief efforts, the people afllicted with Ebola, the confusions and conflicts that have arisen in the course of the epidemic, with exceptional skill. A person requires a deep sense of dedication, a clear sense of the value of his work, to go into situations such as Moore did, and take the photographs he did.
He's one of that small group of global archivists, people who I think of as documenters sent by a higher power, people who have entered into the cauldron in order to gift humanity a true record, a historical archive of great value, depicting with raw honesty lives lived on the edge of catastrophe.
[Above: by John Moore: A burial team from the Liberian health department sprays disin-fectant over the body of a woman suspected of dying EVD on Aug. 14, 2014 in Monrovia.]
In one corner of Liberia, a community has come together to change the course of the dead-
ly epidemic. New cases have been brought to a standstill. This success shows that it's going to take more than extra beds at a ward to stop Ebola.
When Doctors Without Borders arrived in the northern district of Foya in early August, Ebola was out of control. Foya was the first area in Liberia to report cases, and the community has been hit hard.
"At the peak, there were 125 patients in the center," says Katy Athersuch, the local com-munications officer for Doctors Without Borders. "It was a very, very busy time and very stress-ful."
Since then, a lot has changed in this district, which borders Guinea and Sierra Leone. Those changes are the most obvious inside the Ebola care center run by Doctors Without Borders in Foya.
In one of the tents inside the low-risk area, a whiteboard lists every Ebola patient in the center. On this day, there are just three names. "It's a very changed situation," Athersuch says. "For the last six weeks now, we've had an average of around 10 patients. So things are very ob-viously better, but they're not solved." There have been no new cases in Foya for nearly a month -- although patients are still arriving from other areas, including the district of Voinjama only 40 miles up the road.
Health workers say there are two main reasons the epidemic here has been brought under control. One is this care center, which means sick people aren't at home infecting other people. The other is a massive campaign to connect with the community and to distribute information. This work has been conducted by both local health leaders and Doctors Without Borders staff.
Before the medical aid group arrived, people were terrified, says Sylvester Seyoe, a health promoter who lives in Foya. "Every day, all day, you [were] seeing people carrying dead body, dead body, dead body," he says. People weren't just afraid of Ebola. They were afraid of the health care workers, who looked like astronauts and took bodies away in ambulances.
Many people thought the workers were collecting bodies to sell the organs, Seyoe says: " 'Oh, these guys [are] only coming to slaughter people and conduct ritualistic acts and make money out of us.' Because of that, people resisted."
People even distrusted the chlorine sprayed around infected houses and on people arriving at the Ebola care center, says Esthella Jayah, another health promoter from Foya. People be-lieved, she says, that "if you come to the center, they will spray you with the chlorine, and you will die."
So Doctors Without Borders and the local Ebola team put in a new system. Every time an ambulance went to collect a patient or body, they sent a health promoter, like Seyoe and Jayah, to stand outside the house and explain to neighbors what was happening. They also began to al-low families to visit patients at the center -- from a safe distance. One of the most important changes was allowing family members to see the body of someone who died of Ebola, says Mo-ses Follay, a mental health counselor at the Ebola center.
"It is their right to say, 'I want to see the body before it's been buried,' " Follay says. "It is also their right to say, 'I want to see where the body is buried.' " The center even has a viewing area where visitors can see the faces of health care workers before they put on masks, goggles and other protective gear. And just a few weeks ago, the staff at the center installed a cellphone booth where patients can make calls to their friends and relatives.
All these changes have made a big difference in stemming the epidemic here. That's obvi-ous from the community's response to a radio program that lets residents ask questions about Ebola, health promoter Seyoe says.
"They are eager to turn on the radio to listen to the messages from us," he says. Health workers say they're worried that those messages may seem less urgent now that
Ebola is no longer such a deadly presence in Foya. Ebola appeared to retreat once before in this area, only to return with frightening speed, says Katy Athersuch of Doctors Without Borders. The group is determined to make sure that doesn't happen again. Within minutes of my exit from the Ebola care center, an ambulance pulls up, carrying another suspected Ebola patient from the neighboring district of Voinjama. It's a sign that Foya can't yet rest easy.
The next report is by NPR from a Monrovia slum, West Point. This neighborhood has a reputation. A film crew visiting West Point in 2009 noted that West Point is:
...a slum, home to 80,000 people living in conditions that redefine squalor. Miles of rot-
ting garbage surround the slum, which has no sewage system. Pretty much everyone - even the local government officials - defecates and urinates in the open. Drugs, prostitution and armed robbery are the main industries. We got to know some of the residents of West Point, who told us their stories as they smoked heroin and cocaine and begged us for money.
Next we visited a local brothel. The women who lived there talked with us about the U.N. soldiers who have sex with the child prostitutes and beat the older women, and then leave with-out paying.
But perhaps the most revelatory portions of our trip to Liberia came from meeting the ma-jor warlords of the nation's civil wars. There's a tradition in Liberian militias of taking on extrav-agant noms de guerre. Hence, our subjects were named General Bin Laden, General Rambo and General Butt Naked. The latter, in particular, was one of the most notorious Liberian warlords. He claims to have personally killed 20,000 people including babies, and to have sometimes can-nibalized his victims.
Today, General Butt Naked goes by his birth name, which is Joshua. During our time to-gether, he told us that Liberia will surely implode into civil war again when the U.N. leaves next year. But in the meantime, Joshua wants to redeem himself.
He offered us a glimpse of the Liberia that he wants to forge, and we found ourselves growing to like him. He took us to his church, where he rehabilitates child soldiers. We watched as he preached his way through Monrovia on a Sunday...
Monrovia, the capital of Liberia, is under nighttime curfew as that country struggles to contain the Ebola epidemic. On Wednesday, an entire neighborhood in Monrovia was quaran-tined, sealed off from the rest of the city by the government.
The neighborhood is called West Point and it's where a holding center for patients sus-pected of having Ebola was attacked over the weekend. Patients fled, and looters carried off bloody mattresses and other possibly infected supplies. The NPR team in Liberia visited West Point on Tuesday. We spoke to correspondent Nurith Aizenman about the experience.
WWhhaatt iiss WWeesstt PPooiinntt ll iikkee??
It is a sort of finger of land, a little sandy peninsula that juts out from a nicer area of Mon-rovia, abutting a river on one side and the ocean on the other. It's about 800 meters long and 550 meters wide. There are only two roads in that are paved.
The rest is a thicket of shacks and houses and huts, pretty much all one story and built of plywood or cement blocks, with corrugated metal on the rooftops. Between them are sandy pathways. It's so closely packed that in some cases if you're trying to get to your house you have to walk through someone else's house.
Both sides of the paved roads are packed with shops selling all manners of goods, vegeta-bles, fish. There are throngs of people, carrying big buckets on their heads with all sorts of goods. If you drive in, you gently nudge your way forward, parting this sea of people.
Residents had originally found this boy naked on the beach. They dragged him up to a sort of alleyway and put a shirt and pants on him. But beyond that no one wanted to touch him, no one wanted to give him shelter, because it seems he was a child who had been at that holding center for Ebola patients.
A woman went to a nearby health clinic to see if they would take the boy in, but she said the clinic refused because he may have Ebola. The boy was looking very ill at this point. But we heard from someone in West Point that the boy has now been taken to JFK hospital, where the government, with the assistance of the World Health Organization, has just opened the fourth treatment center for Ebola. And although I haven't confirmed it, we heard accounts that the boy seemed to have revived a little bit.
FFOOLLLLOOWWUUPP
Today, John Moore, a Getty photographer spoke to the boy's aunt. She was checking into
a Doctors Without Borders hospital in Monrovia with her five children -- all of them, including her, suspected Ebola cases. The aunt said that Saah died yesterday at JFK hospital.
She said the boy's mother had previously died of Ebola as well. In a country where some believe that the virus isn't real, Saah Exco is now one of more than 500 victims, sealed in a tiny body.
Above: in August West Pointers initiated a mini-rebellion. This popultion is poor, convinced they always get the short end of the stick, and highly resistant to outside attempts to impose
law and order, no matter how helpful it would be. Notice the "Ebola is Real!!" sign.
WWEESSTT PPOOIINNTT AANNDD EEBBOOLLAA
Conditions of life in West Point conspire to make this segment of Monrovia highly sus-ceptible to the predations of the Ebola virus epidemic.
Those residents I've talked with, for the most part differ little from a rural Nevadan resi-dent, an independent human who despises and distrusts the government, any government; they are generally angry about past insults real and imagined, and eventually, when backed into a cor-ner, will appear in war paint, having nothing more to lose.
In the context of the Ebola epidemic, this attitude has made their lot worse because they have been given good advice about preventing infections. Unfortunately, the life saving advice generally gets tossed out along with everything else that flows their way from higher authorities.
The two maps here depict the growth of the Ebola epidemic in Monrovia between Sep-tember 11 and September 20, 2014. For most of my stay I lived in Congo Town. I can see from the maps that Congo Town was one of the least Ebola effected parts of Monrovia. Not surpris-ingly, West Point took a big hit.
This account of the life and death from Ebola [in 2001] of Dr. Mathhew Lukwiya is a lit-erary masterpiece, and a must read. Blaine Harden has captured the deep sadness and valor of the life of a remarkable physician, who was taken by Ebola 13 years prior to the onset of the 2014 epidemic.
"...In the last few hours before he died, Simon Ajok seemed to explode -- first in blood, then in aggravation. The burly male nurse, who had contracted Ebola while caring for patients in an isolation ward at St. Mary's Hospital in northern Uganda, was wearing an oxygen mask when he started to hemorrhage.
The oxygen had turned his blood bright red. It saturated the whites of his eyes and swelled his eyelids to near-bursting. He began to bleed profusely from his nose and gums. Fighting to breathe, Simon ripped off his oxygen mask. He coughed violently, spraying a fine mist of mu-cous and blood onto the wall beside his bed.
Then, to the astonishment and terror of the night-shift staff in the Ebola ward, the 32-year-old nurse hauled himself out of bed. Coughing blood and muttering angrily, he lurched out of his private room and into the long hallway of the ward.
Simon had pulled loose from his catheter. An IV tube dangled from his arm. Babu Wash-ington Stanley was a nurse on duty that night. As he would later recall, he and others on the ward retreated down the corridor while he shouted, ''Please, Simon, go back!'' They were covered head to toe in protective gear -- rubber boots, gowns, aprons, gloves, masks, head caps and plastic eye shields. But they had never seen a critically ill Ebola patient behave like this.
Biomedical researchers admit profound ignorance about Ebola, a viral bleeding fever that first appeared in Africa in the late 1970's. There is no cure, and researchers do not know where the virus hides between human outbreaks. They do know, though, that the blood of an acutely ill Ebola patient is one of the most infectious and deadly substances on earth.
The Ebola epidemic that broke out last fall in Uganda and lasted until January was the largest ever. More than 400 people were infected; 173 died. But the patients there, even those who died, did not suffer the massive and uncontrollable bleeding from nearly every orifice that has made Ebola the dark star of the world's infectious diseases. That is, until the night Simon Ajok erupted.
''Please, Simon, go back!'' Babu Washington Stanley shouted again that night, as his wild-ly agitated colleague stood bleeding in the hallway. Not knowing what else to do, the nurse did what everyone at the 500-bed hospital had done for years, whenever things got out of control.
At 5 a.m. on Nov. 20, he called Dr. Matthew. Dr. Matthew, as he was known to his col-leagues and patients, was the hospital's medical superintendent. He had helped make it one of the best medical facilities in East Africa. He was also a home-grown hero in the scrub savanna of northern Uganda.
Children playing in the dust-blown streets of Gulu, a city a few miles from St. Mary's Hospital, had for years been singing a little ditty about the doctor. In it, they dared each other to jump from a high place. A broken leg would not be a problem, they sang; Dr. Matthew would fix it. In his 17 years at St. Mary's, a Catholic missionary hospital, much of what Dr. Matthew fixed had nothing to do with medicine.
A soft-spoken, deeply religious man of 42, with a wide, easy smile and a slight paunch, he had stood up to a bizarre bunch of local rebels called the Lord's Resistance Army. They said they wanted to run Uganda according to the Ten Commandments. But what they had done for 13 years was kidnap thousands of children and press them into suicidal duty as soldiers. The rebels also abducted and mutilated adults, often slicing off their lips and ears.
When rebels came to the hospital in 1989 to kidnap some Italian nuns living there, Dr. Matthew (who was an evangelical Protestant, not a Catholic) met them at the front gate and per-suaded them to take him instead. He marched around in the bush for a week in his doctor's gown before the rebels let him go. He later opened the walled compound at St. Mary's as a sanctuary from the rebels. Until Ebola scared them away, about 9,000 people entered the grounds of St. Mary's every evening to sleep in peace.
The panicked call from Nurse Stanley roused Dr. Matthew from his bed. His small house was located inside the hospital compound, and the doctor made it to the Ebola isolation ward within five minutes. He suited up, as always, in boots, gown, apron, head cap, gloves and mask. He neglected, however, to put on goggles or a plastic face shield, which can protect the eyes when an Ebola patient coughs. Perhaps he was still groggy from sleep.
Simon Ajok had by then stumbled back to bed, where he was gasping for breath in his private room (one of the meager privileges afforded health- care workers who caught Ebola at St. Mary's). To help him breathe, Dr. Matthew pulled Simon, who was sticky with blood, into a sit-ting position. He then cleaned him up, stripping off his soaked gown and changing the soggy sheets on his bed. Simon died while the doctor was mopping the floor with bleach.
When he finished cleaning up, Dr. Matthew went back to his house, ate some breakfast and then put in another 14-hour day. A few days after Simon died, Dr. Matthew reviewed the events of that night with Dr. Piero Corti, an Italian missionary who, along with his wife, Dr. Lu-cille Teasdale, founded St. Mary's Hospital in 1961 and ran it for decades. Dr. Matthew was his chosen successor.
The more Dr. Corti listened, the more furious he became. He was exasperated by the gamble his protégé had taken. ''I wanted to strangle him,'' said Dr. Corti, who is 75. ''I was think-ing of the future and that he was the man to take care of the hospital for the next 20 or 30 years. But I didn't have the heart to tell him that. He had done what was normal for him to do.''
What was normal for Dr. Matthew was a low-key combination of geniality and unyielding resolve. He flatly refused to allow anyone or anything, be it messianic rebels or bleeding fevers, to destroy his hospital. To that end, he sometimes took chances that threatened his life, that bor-dered on recklessness. Yet he was such a solid medical man, such a devout Christian and such a nice guy that hardly anyone noticed his extraordinary appetite for risk.
For Dr. Matthew, the first hint of an Ebola outbreak in Uganda came on Saturday morn-
ing, Oct. 7, when the telephone rang in his rented house in Kampala. At the time, he was tempo-rarily living in the capital in order to finish up a master's degree in public health. After nearly a decade of running a hospital in the middle of a civil war, he and his wife, Margaret, along with their five children, decamped from the north in December 1998 and moved to Kampala.
''There seems to be a strange disease killing our student nurses,'' said the caller. It was Dr. Cyprian Opira, who was phoning long-distance from St. Mary's Hospital, where he was acting medical superintendent.
The strange illness, Dr. Opira said, had stumped everyone. The usual antibiotics did noth-ing. Stool cultures were not informative. A student nurse began bleeding from the mouth just as she died.
''We need your presence,'' Dr. Opira said on the phone.
Temporary escape from this kind of all-consuming responsibility had been a precious fringe benefit of Dr. Matthew's leave of absence from St. Mary's. He had taken the leave to study at Kampala's Makerere University, telling his colleagues he would come back a better manager.
His wife rejoiced in the move. Kampala was 250 miles and a world away from the trou-bles of Gulu District and the endless responsibility of the hospital. For starters, there was no in-coming artillery. At St. Mary's, a year before the move to Kampala, a mortar shell bounced off a tree and punched through the roof of Dr. Matthew's house in the hospital compound. It crashed on the floor -- without exploding -- not far from the bed where he and Margaret were sleeping.
War was traumatizing the children, Dr. Matthew told his wife, who couldn't have agreed more. The move to Kampala also gave the doctor and his wife a vacation from the demands of his being a very big man in a very poor corner of Africa. Gulu District, which borders Sudan, is part of Acholi land, a semiarid region of goats, cows and subsistence farms long neglected by the government of President Yoweri Museveni. Electricity, for example, is turned off in Gulu on weekends, and it often goes off during the week.
In the tribal calculus that shapes politics and patronage in Uganda and across Africa, the Acholi people are viewed by Museveni's government as suspect. Museveni came to power in 1986 after waging a long guerrilla war against an Acholi-dominated regime.
During that war, Acholi soldiers murdered tens of thousands of Ugandans as part of a sav-age cycle of tribal killing that began in the 1970's under Idi Amin, probably Africa's most famous practitioner of brutal one-man rule. Museveni put an end to the killing and led Uganda into an era of rebuilding and relative prosperity. But Acholi land was largely left behind.
The lack of development and government services in Gulu District has been filled, in part, by successful Acholi men like Dr. Matthew. His extended family, his clan and his tribe all made constant demands on his income, his influence and his kitchen. At their home in the hospital compound, Margaret usually cooked for about 20 people at each meal; eight sat at the dining-room table, five sat in the kitchen and seven or so camped in the living room. Dr. Matthew paid school fees for the children of many of his relatives. They came to him when they were sick. And if they died, he often paid to transport their bodies back to their home villages for burial.
The move to Kampala limited the importuning of the kinfolk. Margaret remembers their 22 months together in the Ugandan capital as the sweetest season of their married life. Dr. Mat-thew loved being back in school, she said. It gave him a chance to study the latest techniques for managing the care of patients whose troubles ranged from poor hygiene to gunshot wounds to AIDS.
School had always been his salvation. He had grown up poor in the northern town of Kit-gum, about an hour's drive from St. Mary's, with no strong kinship ties to the Acholi oligarchy in the Ugandan military. His father was a fishmonger who drowned when he was 12. His mother was a petty trader. She fed her four sons by smuggling Ugandan tea on her bicycle across the border to Sudan, where she traded for soap.
She trained Matthew to be a bicycling smuggler, but it was in the classroom where he paid close attention. He was a phenomenal student, a permanent fixture at the top of his class in grade school, secondary school, university and medical school. With a long string of scholarships as his rope, he pulled himself up from the lowest social rung in one of Uganda's poorest regions to academic acclaim in the capital. Then he immediately returned to Acholi land.
When Matthew first showed up at St. Mary's as an intern in 1983, Dr. Corti, the Italian missionary, remembers that he and Lucille, a surgeon at the hospital, were amazed by the young
doctor's intelligence and gentle ability to lead.
''God sent that man here,'' Dr. Corti said. ''Within three months of his arrival, I told my wife that he is the one who can take over. She smiled and said she was thinking the same thing. People say we groomed him to run the hospital. He groomed himself.''
Dr. Matthew left Uganda for a year in 1990 to take a master's degree in tropical pediatrics at the Liverpool School of Tropical Medicine. As usual, he graduated first in his class. Dr. Ber-nard Brabin, who supervised his degree, said that of all the hundreds of young doctors from around the world whom he has taught in the past decade, Dr. Matthew was one of the most im-pressive.
''First, it was a matter of ability,'' Dr. Brabin said. ''He had a highly critical intelligence that adapted very quickly to complexity. He expressed himself in clear, simple ways. We encour-aged him to stay in the United Kingdom, to teach and pursue higher degrees. But his commit-ment was to the care of children in Uganda.''
Unlike tens of thousands of African professionals who leave the continent for better pay and better lives abroad, Dr. Matthew apparently never even considered such a move. In letters he wrote from Liverpool to Dr. Corti at St. Mary's, he said not to worry about the hospital's future; he would be back. Even if he was to get another advanced degree, he vowed, he would come back and do his research at St. Mary's.
''Have you ever heard of a missionary temperament?'' asked Dr. Brian Coulter, a senior lecturer at the Liverpool School who knew Dr. Matthew well and who visited him at St. Mary's several times in the 1990's. ''That is exactly what Matthew had. His aim in life was to minister to sick children and to run one of the few institutions that function efficiently in Uganda. That is what satisfied him, and that is what he wanted.''
While studying for his second master's degree in Kampala, Dr. Matthew insisted that his children take education as seriously as he did. He read to his twin 9-year-old boys every night, Margaret said, and he pestered his son, Peter, 12, to work harder on math. For the first time in his life, he also had time to relax with his children, to follow British soccer on the BBC and to get a bit thicker around the middle.
All this came to an end, however, when the telephone rang and Dr. Matthew heard the words ''strange disease.'' He left for the north at once, arriving at St. Mary's Hospital in the early evening, in time to witness the death of a nursing student named Daniel Ayella. As the nurse died, the whites of his eyes turned red, and blood dribbled from his mouth. Dr. Matthew had never seen anything like it.
''We thought it was something beyond our knowledge,'' said Dr. Yoti Zabulon, who stood beside Dr. Matthew that night and watched the nurse die. ''We needed help.''
The following day, a Sunday, Dr. Matthew told Sister Maria Di Santo, head of nursing at St. Mary's, that he wanted to see the charts on all patients who had died strangely in recent weeks. He began drawing a map of suspicious deaths. It included 17 patients, two of them stu-dent nurses. Another student nurse was also gravely ill and would soon die.
That afternoon, community leaders from Gulu District came to the hospital. They told Dr. Matthew that whole families were dying in their villages. They demanded something be done. Dr. Matthew and Sister Maria stayed up most of that night, reviewing charts and comparing symptoms with C.D.C. and World Health Organization publications on infectious fevers that cause bleeding. Their suspicion and fear, Sister Maria said, was that it was Ebola. But they had never before treated or seen patients with the disease.
What they read was based largely on what doctors had learned from the last major Ebola outbreak in Kikwit, Congo, in 1995, where 318 people got sick and 4 out of 5 of them died. The literature explained that close physical contact, especially unprotected exposure to an infected person's body fluids, caused most new infections. The publications also explained that the sicker a patient becomes, the more dangerously infectious he or she is. Touching dead bodies, the litera-ture said, was a major risk.
As Dr. Matthew well knew, the dead-body factor was especially alarming in Acholi land, where tradition demands that female relatives of the deceased work together to wash and dress a corpse. After a body has been buried, those in the funeral party wash their hands together in a common basin, joined by other mourners from the village. The tradition symbolizes solidarity, but during an Ebola epidemic it was a recipe for catastrophe.
''By morning it became obvious to Dr. Matthew that it was some kind of hemorrhagic fe-ver in our hospital,'' Dr. Zabulon said.
''He said, 'Let's go around the usual bureaucracy and call Kampala.' ''
The call was taken by Dr. Sam Okware, Uganda's commissioner of community health ser-vices, who dispatched a team to Gulu from the Uganda Virus Research Institute. When they ar-rived to collect blood samples, Dr. Matthew had already begun to move suspected Ebola patients into an isolation ward that he had set up following W.H.O. guidelines.
Sub-Saharan Africa is widely viewed as incapable of dealing with epidemics -- for exam-ple, AIDS. In countries like South Africa and Zimbabwe, where a fifth to a quarter of the adult population is infected, AIDS will kill around half of all 15-year- olds, according to the United Nations. Around the world there are 16 countries where H.I.V.-prevalence rates exceed 10 per-cent.
All 16 are in Africa. Uganda, however, happens to be a can-do kind of place when it comes to public health disasters. It dropped off the United Nations list of countries most affected by AIDS because its government was the first in Africa to launch a substantial awareness cam-paign. It distributed millions of free condoms and relentlessly explained how H.I.V. is transmit-ted by sexual contact. The campaign is credited with lowering the infection rate to 8 percent, from 14 percent in the early 1990's.
''Transparency, openness and modern communications, that is what we use,'' said Dr. Okware, the former head of Uganda's AIDS control program who was quickly named chairman of its National Ebola Task Force.
When lab tests confirmed Ebola, the Ministry of Health contacted the W.H.O., the C.D.C. and major donor nations and called a news conference. It hired more than a thousand ''local in-formants'' in 346 villages in Gulu District. They went from hut to hut, looking for sick people, who often were hidden by their families. Ebola burial teams were trained and outfitted with pro-tective clothing. In parts of the district where the Lord's Resistance Army is active, the army dis-patched armored personnel carriers to search for the sick and collect bodies. Ebola alerts filled the newspapers and state radio.
''All dead bodies should be immediately buried in sacks made of polyethylene materials,'' said one typically blunt public-service announcement in a Kampala daily. The campaign worked, but it also caused some panic. According to Dr. Okware, rural people burned villages where Ebo-la was rumored to be. Officials in neighboring Tanzania and Kenya seemed to suspect that all Ugandans carried Ebola, screening them at the borders and sending hundreds home. Saudi Ara-bia banned Ugandans from the hajj. Even the Lord's Resistance Army blinked, releasing 40 ab-ductees it feared were infected.
Across northern Uganda, there was panic buying of Jik, a brand of household bleach man-ufactured in Kenya. Ebola burial teams used the stuff to soak sickbeds, douse bodies and sterilize themselves after a burial. As a result, some rural Ugandans worshiped Jik as a ''miracle drug,'' according to Dr. Paul Onek, director of health services in Gulu District. He said they kept a bot-tle around the hut as a talisman to scare off Ebola. People bathed in bleach and some drank it.
''I have heard that some of you are drinking Jik to stop infection right from the stomach,'' Ronald Reagan Okumu, a member of Parliament from Gulu, said at a news conference on Oct. 30. ''Nobody should drink Jik.''
That same day, several hundred Acholi traditionalists took matters into their own hands in Gulu town. They tried to chase out the virus by shouting, running around with spears and beating on saucepans. They told Ugandan journalists they intended to exorcise the evil of Ebola and send it south toward Kampala.
The patient load at St. Mary's soared in the week after Ebola was confirmed. By the third week of October, with the number of patients approaching 60, the three doctors, five nurses and five nursing assistants who had volunteered to work on the isolation ward were overwhelmed.
They could not handle the load, in part, because of the time and personal attention that they gave to each Ebola patient. In other African hospitals, the treatment strategy was entirely different. Doctors encouraged a spouse or family member to be the primary caregiver for each patient. Wearing protective clothing, caregivers cooked for and cleaned up after their loved ones. The system reduced risks for nurses and nursing assistants, keeping them away from infectious body fluids.
Dr. Matthew, however, kept all kin away from infectious patients. He allowed only doc-tors, nurses and nursing assistants to go near them. His system helped contain the epidemic, re-ducing sickness and mortality rates among family members. At the same time, though, it placed health-care workers in close quarters with highly infectious patients and increased their chances of contracting Ebola. Whether it was against rebels or viruses, Dr. Matthew made a habit of tak-ing personal risks for the sake of his hospital. In a pleasant but dogged way, he insisted that his nurses do likewise.
''There is no right answer to the question of how to nurse Ebola patients in Africa,'' said Dr. Daniel Bausch, a C.D.C. medical epidemiologist who worked in northern Uganda last fall and managed the Ebola ward at a small government hospital in Gulu town. In many African hos-pitals, it is less a matter of best medical opinion than of what is possible. Dr. Bausch used family caregivers on the Ebola ward at Gulu Hospital because he said he had no reasonable alternative. St. Mary's, though, had the facilities and the personnel to take on the care and feeding of Ebola patients without family help.
Whatever its medical or epidemiological value, Dr. Matthew's system became a manage-ment nightmare. He tried to reassure nurses and nursing assistants that the risk was tolerable. Yet as the weeks went by, Ebola insidiously eroded his authority. Health-care workers wore their protective gear, they managed their risks and still they got sick. Twelve of them died.
''With each death, the tension built,'' said Sister Maria. ''You could feel the atmosphere. It was building toward a climax. There were so many questions and no answers.''
To keep his volunteer nurses from bolting, Dr. Matthew tried to lead by example. He was in the Ebola ward every morning at 7 and he finished up around 8 in the evening. As he made his rounds, he preached caution.
''Think with your head, not with your heart,'' he shouted at one nurse in late October, when she rushed to clean up after a patient who had vomited on the floor. Dr. Matthew instructed the nurse to douse the vomit with bleach before going near the patient. In the evenings after leaving the isolation ward, Dr. Matthew visited the many foreign doctors who had set up laboratories and were helping to care for patients at St. Mary's, as well as at nearby Gulu Hospital.
As they ate their dinner in the compound of his hospital, he questioned them about patient care, searching for ways to keep his nurses from getting sick. Dr. Bausch, the C.D.C. medical epidemiologist who joined in these chats nearly every night for two months, said no one could give Dr. Matthew a satisfactory reason why the nurses were getting infected.
''Very few of these nurses had ever been in a situation where they had to put on gowns, gloves, masks and wash their hands after every contact with every patient,'' said Dr. Bausch. ''Dr. Matthew was in a situation where he had no choice but to herd around inexperienced peo-ple who didn't want to be there.''
The pressure on him was unending. But Dr. Bausch said that through it all Dr. Matthew was ''a very kind, very mild-mannered guy who liked to make jokes,'' especially about the endless American presidential election. ''He didn't seem as stressed as a lot of people would have been.''
Privately, Dr. Matthew was afraid -- for himself and for the hospital. He did not want his wife or his children to come near him. On Oct. 14, he wrote to Margaret in Kampala: ''I will not be able to come to you there because we are very busy, and secondly because it would be dan-gerous to you, in case I am incubating the disease, although it is very unlikely. You should not also come here! The situation is very bad.''
The situation in the hospital became a whole lot worse in late November. By then, the na-tional Ebola epidemic had peaked, and the number of new cases was beginning to fall. Not so for patients and nurses inside St. Mary's. During a 24-hour period that ended at dawn on Nov. 24, seven people died of Ebola, including three health-care workers.
Two of these workers were nurses who did not work in the Ebola ward. By breakfast, news of their deaths was causing panic. If nurses who stayed away from the isolation ward could die, it seemed that anyone could die. Nurses mutinied. The day-shift staff did not show up for work. Instead, at 8:45 a.m., about 400 health-care workers, nearly the entire staff at St. Mary's, packed into the assembly hall of the hospital's nursing school.
''We were very many and we were so scared and we were a bit aggressive somehow,'' said Margaret Owot, a nurse who attended the meeting and who worked on the Ebola ward. ''Ebola was a disease that no one knows how it is killing, and the nurses thought everybody would die.''
When Dr. Matthew heard about the meeting, he rushed to the assembly hall and demanded to know what it was that the nurses wanted. ''We are thinking that the hospital should be closed,'' one nurse shouted.
By this time, Dr. Matthew was well versed in the art of persuading frightened health-care workers to swallow their fear. He had made a series of inspirational speeches at staff meetings and funerals. At the largest of those funerals, for an Italian nun who died of Ebola, he had spoken on Nov. 7 of the responsibilities of love.
''It is our vocation to save life,'' he said then, in a talk recorded by the Rev. Matthew Odong, the vicar general of the Catholic archdiocese of Gulu and Dr. Matthew's longtime friend. ''It involves risk, but when we serve with love, that is when the risk does not matter so much. When we believe our mission is to save lives, we have got to do our work.''
But on the morning of the mutiny, which happened to be his birthday, Dr. Matthew appar-ently concluded that inspirational rhetoric would not keep the hospital open. So he used threats. ''If the hospital is closed, I will leave and I will never come back to Gulu,'' he said, according to Owot.
He had their attention. With the assembly hall stone silent, Dr. Matthew told the nurses, most of whom he had helped train, the story of how he had volunteered to be kidnapped by the Lord's Resistance Army. He had been afraid the rebels would kill him, but he took the risk to protect the hospital and keep it open for patients who had no place else to go.
The kidnapping tale laid out the principles that governed his life and the circumstances under which he was willing to risk losing it. By telling the story, he challenged the nurses to live, and perhaps to die, by the values that had brought them into nursing in the first place.
If you abandon the hospital because of fear, he concluded, many patients will die, and you will be responsible.
''For me, I felt that he gave us really a fatherly word,'' said Owot, a nurse who has worked at St. Mary's for 16 years. ''He made me see that if the hospital is closed and I fall sick, where would I go? Who would nurse me?''
At another long and contentious staff meeting in the same hall that afternoon, Dr. Mat-thew shifted back to inspiration, which was much more his style. He could not force them to stay, he said, but he would continue fighting Ebola, alone if necessary, until the virus was beaten or until he was dead.
He joined the nurses in a song. The mutiny was over. That evening, his wife called him, and all his children came on the line to sing ''Happy Birthday.'' But Dr. Matthew was exhausted. ''Margaret, I cannot talk,'' he told her. ''I need to rest.''
A total of 29 health-care workers contracted Ebola in Uganda, and 17 of them died, ac-cording to the C.D.C. Exactly how any of them got infected is not known with a high degree of certainty. But there is a consensus among doctors who worked in Uganda, as well as in Congo during previous Ebola outbreaks, about how the infection is not spread.
Simply breathing in the vicinity of people who are infected with Ebola is unlikely to make you sick. Ebola is not a ''free virus'' that floats around for hours in the air of an isolation ward. ''There has to be a real line of transmission,'' Dr. Bausch said. That means direct contact with body fluids, like vomit, blood or sweat. But the experts agree that a coughing patient who is spraying mucous or blood into the air is also a threat.
''It is not known if this spray landing on bare skin is enough,'' said Simon Mardel, a W.H.O. consultant who often made rounds with Dr. Matthew. ''It seems most likely that there has to be a break in the skin. When a patient coughs, a much more likely route of inoculation for a health-care worker is the mouth, the nose or the eyes.''
Experts guess that many of the health-care workers who got sick in Uganda made a small mistake. Their protective clothing, in the equatorial heat, may have made them uncomfortable or claustrophobic. After touching a patient, they may have gotten careless and slipped a gloved fin-ger inside their protective mask to scratch an itchy nose or rub a sweaty eye.
Almost none of the health-care workers in Uganda wore goggles at all times inside the isolation wards. They quickly fogged up. As a result, a nurse couldn't find a vein for a blood sample. A doctor couldn't see a patient's face or read a chart.
''I would have my goggles on, but if I got close to a patient to listen to his lungs, I would put my goggles down,'' said Dr. Bausch, who makes his living by working around the world's
most infectious viruses and describes himself as ''incredibly careful.''
During the epidemic in Uganda, complaints about foggy goggles resulted in shipments of, among other things, plastic face shields that look like upside-down hockey masks. They did not fog up like goggles, but they were far from perfect. Open at the top, they left room for particles of coughed blood to drift down into the eyes.
Like most of the doctors and nurses, Dr. Matthew did not always wear eye protection. Ba-bu Washington Stanley, the night-shift nurse who called him out of bed on Nov. 20, the night Simon Ajok erupted in blood, clearly remembers that the doctor did not put on goggles or a plas-tic face shield that night.
Although no one can be sure, this lapse may have been what infected Dr. Matthew. In his rush to help a dying nurse whom he had helped train, he violated his own rules. He thought with his heart. Two days after his birthday, on a Sunday Night, Dr. Matthew called his wife. She was startled by the sound of his voice. He was heavily congested and coughing.
''Margaret,'' he said, ''I have a terrible flu.'' Monday morning he had a fever. At the hospital infirmary, he told Sister Maria he had
malaria. She agreed it must be malaria. ''We said malaria, but we thought Ebola,'' Sister Maria said.
The fever grew worse as the day went by. He canceled meetings and went home to bed. By Tuesday, antimalarial drugs had not brought down his fever. By Wednesday morning, he was vomiting, and he found it difficult to keep liquids down. Dr. Pierre Rollin from the C.D.C. ran blood tests. They were done at a lab on the hospital compound.
That night, Grace Obuu, 24, who became a nurse at St. Mary's after Dr. Matthew and his wife adopted her, went to his house. He was alone, and she put him on an IV drip to help keep him hydrated. His fever was high, and he was very weak, the nurse said, but he had stopped vomiting. She was startled by the sound of his voice. He was speaking loudly and distinctly, and he was not talking to her.
''Oh, God, I think I will die in my service,'' he prayed. ''If I die, let me be the last.'' Then, in a powerful voice, he sang ''Onward Christian Soldier.''
Two years earlier in a Pentecostal church in Kampala, Dr. Matthew had delighted his born-again wife by raising his hand and announcing to the congregation that he, too, was born again. Always a churchgoing Protestant, he had since been going to church twice a week, until the ''strange disease'' called him away from Kampala. The blood test came back positive for Ebo-la.
''When I told him, he himself asked to go to the isolation ward,'' Dr. Rollin said. ''He said, 'Since I am the boss, I should show an example.' ''
A telephone call was finally placed on Thursday afternoon to Margaret, who had heard nothing since Sunday night. Dr. Matthew had not wanted her called, saying he feared that she would take the call on her mobile phone while driving in traffic and would get in a wreck.
She was sitting on a sofa at home when the phone rang. She immediately packed her bag, hired a taxi and left for Gulu. But she was late reaching an upcountry bridge across the Nile Riv-er. Soldiers block it at night as a security measure against the Lord's Resistance Army. Margaret had to sleep in the taxi.
On Friday morning at 9:30, dressed in protective gear, including goggles, she approached her husband's bedside. He was in Room 4 in the Ebola ward, next to the room where Simon Ajok died 11 days earlier. At the sight of him, Margaret began to cry, and she rushed toward his bed to hug him.
''Don't you come close to me!'' Dr. Matthew warned. ''You will get infected.''
He called a doctor, who brought Margaret a stool. She sat about three feet away. ''You can't stay here when you are crying,'' he told his wife. ''You will get infected. You
don't have to cry. You have to be strong and only pray.''
She stopped crying. He asked her how the children were doing in school. He was particu-larly worried, she said, that Peter was not paying proper attention to math. After about 15 minutes, he seemed tired, and she left. That evening, he was stronger, as Margaret remembers, and his eyes were clear. He said that he probably got Ebola from Simon Ajok, and he struggled to explain why he took the risks that made him ill.
''Look, Margaret, it is a rough time, I know,'' he said. His wife recalled his words with reverent precision, as if she were reciting from Scripture. ''You were not expecting this. God's will is not our will. I did not also expect to get, you know, infected. But being a person working in the foreground in this place, anything can happen. A mechanic can get his hands chopped off in a machine. Even a woman when she is cooking can get burned. So you just have to accept the situation.''
Margaret became angry. ''Now I can't even touch you,'' she told him. ''I can't even nurse you. I can't do anything. I just have to sit aside like a traitor.''
''You have to accept your fate,'' he replied. ''I don't want you to get infected. If anything happens to me, at least you will be alive to look after my children.''
On Saturday, his breathing was worse. He found it difficult to speak. Ignoring his warn-ings, Margaret moved close enough to touch her husband through the four surgical gloves she wore on each hand. During her 20-minute visits, she held his foot.
Dr. Matthew was getting weaker by the hour, exhausting himself as he fought for breath. On Sunday afternoon his doctors asked Margaret's permission to put him on a respirator. She gave permission, but before the machine was hooked up, she went to his bedside and asked him to pray with her.
''I said, 'Be strong, fight this sickness with the blood of Jesus,' '' Margaret said.. He com-plained that he was dry and, until the doctors shooed her away to hook up the respirator, she slipped ice cubes into his mouth with her gloved fingers. The breathing machine seemed to be the answer.
When Margaret left her husband's bedside early Monday evening, his fever had come down, the oxygen level in his blood had risen and his pulse was near normal. One doctor told her it was a miracle. Late Monday night, however, his lungs hemorrhaged. This was the worst-case scenario his doctors had feared, and they could do nothing.
Dr. Matthew died at 1:20 a.m. on Dec. 5. By the time Margaret was notified and ran to the Ebola ward, he had been zipped up in a polyethylene body bag. She asked that it be unzipped just a little so she could see his face for the last time. The corpse, she was told, was too infectious.
Doctors who treat Ebola are not convinced that they have a whole lot to offer any patient. They estimate that using IV drips to replace lost fluids might make a difference for about 10 per-cent of those who get sick. For others, they guess, the seriousness of the illness depends on the genetic makeup of a patient, the amount of tainted blood or other body fluid that has come in contact with a patient and the route of infection. The prick of a bloody syringe, for example, is almost certainly worse than a cough in the face.
It also depends on the strain of the virus. In Congo in 1995, about 80 percent of those in-fected with Ebola died. But the strain of the virus that the C.D.C. isolated in northern Uganda was different from what they found in Congo and considerably less deadly.
It was identical to a strain that caused two Ebola outbreaks in nearby southern Sudan in the late 1970's. There, in a place where medical care was all but nonexistent, the death rate was around 50 percent -- roughly the same as it was last year in the best Ugandan hospitals. The numbers suggest that modern medicine, at least so far, is helpless to change the rate at which the various strains of Ebola kill human beings.
''Ebola is a tough disease,'' Dr. Bausch said. ''I am not so sure that once someone is in-fected that the treatment we offer prevents more people from dying than would have died any-how. The saddest example of that is Dr. Matthew. When he got sick, people pulled out all the stops. But it didn't matter.''
Ebola is also finicky, depending on who gets infected. The same viral strain, acquired in the same way on the same evening, from the same infectious patient, can kill one person, while giving another a headache. Babu Washington Stanley, the night- shift nurse, also got sick with Ebola nine days after he and Dr. Matthew struggled to care for Simon Ajok. Stanley, though, came down with the mildest case of Ebola on record in Uganda. He had a headache for a few days, and then it went away. Ebola made him hungry, he said, especially for liver. Now he is fi-ne.
There is an amateur videotape of Dr. Matthew's burial. It is almost unbearable to watch. According to a will he wrote in the Ebola ward in the days before his death, a grave was chosen inside the hospital compound beneath a towering banyan tree. It lay beside the grave of Lucille
Teasdale, the surgeon who was the wife of Dr. Corti. Dir. Teasdale, who died of AIDS she con-tracted while operating on patients at St. Mary's, had been Dr. Matthew's mentor, champion and great friend.
Since his body was highly infectious, he was buried the day he died. An Ebola burial team, dressed in protective gear that seemed suitable for a lunar landing, rolled up to the grave site at 4 p.m. in a white ambulance. They whisked a simple wooden coffin out of the ambulance and lowered it into the grave with ropes. All the while, one member of the burial team sprayed the coffin, the ropes and his colleagues with Jik bleach. More a disposal procedure than a burial, it was over in less than five minutes.
On the videotape, at the moment the ambulance comes into view, the soundtrack explodes with the screaming of nurses. Earsplitting and inconsolable, in voices that fused grief, exhaustion and rage, their shrieking was the hopeless music of the funeral. The nurses were part of a crowd of several hundred people who had been warned to stay well away from the grave until it was covered with dirt.
Margaret stood at a distance with her children. She had insisted that they witness the buri-al. Otherwise, she believed it would be impossible for them to accept their father's death. They arrived from Kampala just 30 minutes before the service.
Many government officials, including the minister of health, had also rushed north to Gu-lu. During the height of the Ebola epidemic last fall, Dr. Matthew had been quoted almost daily in the Ugandan press. He had become a national icon: the fearless field commander at the center of a biological war that threatened everyone in the country. Even though the Ebola outbreak had been all but defeated by the time he died, Dr. Matthew's death rattled the country's self-confidence, suggesting somehow that the center could not hold.
For a time, the doctor's death paralyzed Uganda's fight against what was left of the Ebola epidemic. St. Mary's Hospital stopped admitting new Ebola patients. Across Gulu District, a number of health-care workers quit. Suspected Ebola patients refused to be taken to hospitals. According to Dr. Onek, the health officer for Gulu District, local people were asking, ''Why go to the hospital, if the big doctor has died in the hospital?''
Six weeks after the funeral, during a long and mournful conversation about the conse-quences of Dr. Matthew's death, Sister Maria said St. Mary's had not yet recovered, and she doubted that it ever would. The hospital has not been able to find a new medical superintendent.
''You know, so many people relied on him,'' she said. ''He had clear ideas about what to do with the future of the hospital. We have lost a guide. He was so clever in a way of talking to you kindly. He could lead people. That is what we have lost.''
Margaret, too, felt lost. President Museveni praised her husband's courage and promised her about $2,800 as a special death benefit. But that would not be nearly enough, Margaret said, to finish building a house in Kampala or to send five children to university, as her husband had planned. She said she did not know how she would be able to honor his wishes.
The doctor who made the mistake of thinking with his heart left far more behind than a vacuum. Epidemiologists who traveled to Gulu credit Dr. Matthew with helping to contain Ebola before it could spread. His insistence on immediately calling senior health officials in Kampala jump-started the government's public-awareness campaign. He may have saved hundreds, per-haps thousands, of lives. As important for containing future outbreaks, C.D.C. virologists said his support for their research means that Uganda's epidemic should produce more scientific data on Ebola than all the other outbreaks in Africa combined.
''If you need it, you have it,'' Dr. Matthew told foreign researchers when they descended on Uganda, according to Dr. Rollin. Access to St. Mary's laboratories allowed researchers to pre-serve a vast number of blood samples from Ebola patients at every stage of infection.
The samples could help them discover how Ebola triggers a cascade of immunological events that turn the body's defenses against itself, transforming white blood cells into subversive agents that trigger bleeding. The samples could also help them understand -- and perhaps one day invent a drug to inspire -- the remarkable immune response that allowed Babu Washington Stan-ley to shake off Ebola as if it were a mild hangover.
Father Odong, the vicar general of Gulu, said that he hoped his friend's story will offer his fellow Africans a new definition of what it means to be a big man in Africa. ''It is not about get-ting rich and having power,'' he said. ''We should tell everyone the story of Dr. Matthew.''
Whether or not his story survives, its last chapter did turn out as Dr. Matthew had hoped. His hospital and his nation defeated Ebola, at least this time around. With no new cases in the previous 21 days, W.H.O. declared on Feb. 6 that the epidemic was effectively over.
The isolation ward at St. Mary's has been closed and scrubbed down and will reopen this month as a children's ward. And Dr. Matthew's solitary prayer in the week before he died was answered: among the health-care workers who fought Ebola at St. Mary's, he was the last to die.
Above: Ibrahim Fambulle in an Ebola ward -- a closed primary school originally built
by USAID -- in Monrovia. (Photo by John Moore/Getty Images)
As U.S. troops begin arriving in Liberia to help contain the regional spread of Ebola, a physician in the capital is grappling with the virus upfront. Dr. Martha Zarway's life turned up-side down when one of her clinic staff members -- a friend -- died on Sept. 2 amid rumors that the cause of death was Ebola.
It was not so long ago that Zarway, 53, survived Liberia's civil war, dodging bullets as re-bel groups fought for control of Monrovia and other parts of the country. Just as Liberia was struggling back to its feet, the Ebola outbreak came and dealt the people there a body blow.
Health workers like Zarway, a private general practitioner who operates her own clinic, are bearing the brunt of the virus. So far, at least 85 health workers in Liberia have died of Ebola.
"The truth is, the entire thing is scary," she says. "But at the same time, I usually tell my staff, it's scary -- but think about a war, and all the soldiers run away. What will happen to the civilians?"
Pouncing on her military theme, I ask whether she feels like an army general who has to rally her foot soldiers.
"Like I say, it's scary, it's double scary," she says. "But you can't run from the field. I mean, I can't change my profession. I'm a doctor. I'm a doctor, so we can't run away."
I ask her if there are similarities between living through this Ebola outbreak and living through Liberia's 14-year civil war, which ended about a decade ago.
"There are similarities and yet there's a big difference, because this one -- I think it's more scary. It seems that you can't hide. ... We used to say, 'Let we go down the basement to hide from the gunshots,' " she says. "But this one, you can't hide -- especially being a medical practitioner. There's no way to hide."
Zarway set up her clinic five years ago in Paynesville, a Monrovia suburb. She and her staff treat all kinds of patients, from pregnant women to diabetics. They also deliver babies. Zar-
Whether or not his story survives, its last chapter did turn out as Dr. Matthew had hoped. His hospital and his nation defeated Ebola, at least this time around. With no new cases in the previous 21 days, W.H.O. declared on Feb. 6 that the epidemic was effectively over.
The isolation ward at St. Mary's has been closed and scrubbed down and will reopen this month as a children's ward. And Dr. Matthew's solitary prayer in the week before he died was answered: among the health-care workers who fought Ebola at St. Mary's, he was the last to die.
Above: Ibrahim Fambulle in an Ebola ward -- a closed primary school originally built
by USAID -- in Monrovia. (Photo by John Moore/Getty Images)
As U.S. troops begin arriving in Liberia to help contain the regional spread of Ebola, a physician in the capital is grappling with the virus upfront. Dr. Martha Zarway's life turned up-side down when one of her clinic staff members -- a friend -- died on Sept. 2 amid rumors that the cause of death was Ebola.
It was not so long ago that Zarway, 53, survived Liberia's civil war, dodging bullets as re-bel groups fought for control of Monrovia and other parts of the country. Just as Liberia was struggling back to its feet, the Ebola outbreak came and dealt the people there a body blow.
Health workers like Zarway, a private general practitioner who operates her own clinic, are bearing the brunt of the virus. So far, at least 85 health workers in Liberia have died of Ebola.
"The truth is, the entire thing is scary," she says. "But at the same time, I usually tell my staff, it's scary -- but think about a war, and all the soldiers run away. What will happen to the civilians?"
Pouncing on her military theme, I ask whether she feels like an army general who has to rally her foot soldiers.
"Like I say, it's scary, it's double scary," she says. "But you can't run from the field. I mean, I can't change my profession. I'm a doctor. I'm a doctor, so we can't run away."
I ask her if there are similarities between living through this Ebola outbreak and living through Liberia's 14-year civil war, which ended about a decade ago.
"There are similarities and yet there's a big difference, because this one -- I think it's more scary. It seems that you can't hide. ... We used to say, 'Let we go down the basement to hide from the gunshots,' " she says. "But this one, you can't hide -- especially being a medical practitioner. There's no way to hide."
Zarway set up her clinic five years ago in Paynesville, a Monrovia suburb. She and her staff treat all kinds of patients, from pregnant women to diabetics. They also deliver babies. Zar-
way says they all take precautions, wearing protective equipment and diplomatically asking pa-tients if they've come in contact with or looked after people who are sick with Ebola.
In Monrovia these days, campaigners all over the city are trying to raise awareness about Ebola. They sing and play drums, and use bullhorns to spread the word about how to avoid the virus.
But at Zarway's clinic, Ebola quietly crept into their midst when their colleague died, with fear and stigma attached. Rumors circulated that he died of the virus. In fearful times, there was finger-pointing at the staff and the clinic. They had to relocate temporarily. The original clinic had to be disinfected. Despite the upheaval, Zarway says, most of her staff have chosen to stay on.
"So far only one person is scared to come back to work," she says. "One nurse decided to stay home. ... This is our first time having to see and deal with Ebola, so we are adapting."
Now that Zarway has become a potential contact person herself -- being monitored for possible infection because of the questions about the late colleague she looked after -- she says the toughest part is the no-touching rule, refraining from physical contact with others. "I tell my little son, 'No, you can't touch Mummy until after the 21 days,' " she says.
That's the three-week virus incubation period for those who might have come into contact with Ebola and could test positive. So, no touching, no hugging, no kissing. That's the hardest, she says.
"During the war, we could hug each other and give some comfort," she says. "But now, with Ebola, you have to be careful. You have to stay distance apart."
Zarway had to try to explain all this to her young son. But how does the rest of her family feel?
"To tell you the truth," she says, "I haven't told my husband yet. He's in the States. I have to tell him today, you know, but it's scary."
Later, I asked her how the call went. Zarway told me she'd been praying that her husband wouldn't tell her to slow down. She still loves her job, despite the hazards of Ebola. He didn't ask her to quit. And her clinic is still up and running.
On Monday Liberian health officials reported the death of Dr. Abraham Borbor, deputy chief medical doctor of the country's largest hospital and one of the recipients of the experi-mental Ebola treatment drug ZMapp, which was also given to two infected American aid work-ers.
Several challenges have made the current outbreak difficult to contain. Healthcare systems in the countries hit hardest by the virus are rudimentary and were quickly overwhelmed as the number of cases climbed.
Also, the infections have not been confined to rural areas as in previous Ebola outbreaks, making it harder to identify undiagnosed patients. A number of health workers in the affected countries have reportedly refused to treat Ebola patients out of fear of contracting the disease. forcing the closure of several hospitals and clinics throughout the region.
When word spread through Sierra Leone's capital that Dr. Martin Salia had died this morning, a throng of patients and colleagues rushed to the gate of one of the hospitals where he had worked to find out if it was really true.
"People were crying, people were wailing, they were shouting. Some of the staff who came around were rolling on the ground," says Leonard Gbloh, administrator of Freetown's Kissy United Methodist Hospital, who witnessed the scene. "We're in a state of shock. We are really mourning the death of a great hero."
In a country with precious few doctors -- there were only 136 physicians to serve a popu-lation of 6 million before Ebola hit, and the disease has already claimed five of them -- Salia's death is being met with dismay and disbelief.
The shock has been all the greater because of reports that Salia had been in relatively good condition before he left Sierra Leone for the University of Nebraska Medical Center, where he arrived on Saturday. The doctor was able to walk to the ambulance waiting to take him to the medevac plane, says Dr. Komba Songu-Mbriwa, lead clinician at the Hastings Ebola Treatment
Center in Freetown, where Salia was initially cared for. He climbed in without assistance and even carried his documentation papers. "He was pretty stable," says Songu- Mbriwa.
There was also the perception that Salia, who is a legal permanent resident of the U.S. And whose wife and two children live in Maryland, was en route to the best possible care.
"When we're talking effective treatment, medical treatment, we think the U.S. comes first," said Gbloh. "Cases that will go to the U.S. we are always pretty sure that the patient is go-ing to make it. We thought that he was going to come back."
But the doctors who cared for Salia in Nebraska said that by the time his plane touched down on U.S. soil, after 16 1/2 hours in the air, he was critically ill. They said he had lost kidney function, was working hard to breathe and was unresponsive. He was treated with the experi-mental Ebola drug ZMapp and also received a blood plasma transfusion from an Ebola survivor.
The impact of Salia's illness on Freetown's fragile health system has already been felt. Sa-lia was both the medical director of Kissy Hospital and the only full-time doctor. As the only person qualified to perform surgery, he worked on cases ranging from appendicitis to difficult births there and at two other hospitals in the city.
At another of the facilities where Salia worked -- Connaught Hospital -- he often per-formed surgery for free. Gbloh said it will be hard to replace him. After Ebola hit, surgery was suspended at Kissy Hospital. Since Salia's infection the hospital has, as a precaution, suspended even non-surgical care for 21 days, the incubation period for the virus.
Ebola is surging in Freetown, and even health workers like Salia, who work at regular hospitals rather than at Ebola treatment centers, can unwittingly end up treating a patient who has the disease. As far as his colleagues are aware he did not come in contact with a patient who had been diagnosed with Ebola, yet patients he treated could have been infected. That only under-scores just how risky it is to practice medicine in Sierra Leone today.
DDRR.. AADDAADDEEVVOOHH 2200 OOCCTT
As Nigeria heaves a collective sigh of relief after being declared free of Ebola, one wom-an is being widely praised for helping to ensure a more devastating outbreak was avoided. Dr. Stella Ameyo Adadevoh raised a red flag when attending to a Liberian patient at the First Con-sultant Hospital in Nigeria's main city, Lagos, in July.
Patrick Sawyer had just flown into the country, already sick -- he should never have been allowed on the plane. Nigeria had never had an Ebola case before so it was an impressive piece of diagnostic work. Whilst caring for Mr. Sawyer and protecting the nation from the virus, Dr. Adadevoh and her colleagues were themselves at great risk.
"From the day the index patient arrived in Nigeria, my father and I were constantly ask-ing my mother and making sure she was OK. We were aware of what could come," says Bankole Cardoso, Dr. Adadevoh's only son.
"She was fine all along and then suddenly it became apparent. We were seeing little signs and so of course there was panic and confusion," says the 26--year--old.
These were the early days of the Ebola outbreak and Nigeria was not ready. Dr.. Adadevoh had already gone to inspect Lagos's rudimentary Ebola treatment centre, and had de-scribed it as "uninhabitable", Mr. Cardoso says.
"So, when she had to go in she was, of course, very worried," recalls Mr. Cardoso who followed behind the ambulance in his car. Dr. Adadevoh had earlier already won a different bat-tle -- to isolate Mr. Sawyer. He had not taken kindly to being told he could not leave.
"Immediately, he was very aggressive. He was more intent on leaving the hospital than anything else," says Dr. Benjamin Ohiaeri, the director of First Consultant Hospital. "He was screaming. He pulled his intravenous [tubes] and spilled the blood everywhere."
It has been suggested that Mr. Sawyer, who had already lost a sister to Ebola, was not in-terested in medical assistance as he had set his mind on visiting one of Nigeria's popular Pente-costal churches in search of a cure from one of the so--called miracle pastors. During those early days caring for Mr. Sawyer whilst awaiting the result of the blood test, Dr. Adadevoh came un-der intense pressure to let him leave -- a move that could have had catastrophic consequences.
"The Liberian ambassador started calling Dr. Adadevoh, putting pressure on her and the institution. He felt we were kidnapping the gentleman and said it was a denial of his fundamental rights and we could face further actions," says Dir. Ohiaeri, adding that the hospital trusted Dr.
Adadevoh's judgment.
"The only way we could be sure and live up to our responsibility to our people, the state and nation -- this is all about patriotism at the end of the day -- was to keep him here."
Mr. Sawyer died in the hospital of Ebola. Dir. Adadevoh and eleven of her colleagues caught the virus..
"On the first day I was able to come close and at least stand by the window and have a conversation with her, the second day the same thing," he said. "I took her things to make her comfortable -- towels and slippers and then suddenly the next day I couldn't even go near the window," he added, pointing out that health officials imposed stricter rules on isolating Ebola patients. "As every day went on she was there -- it appeared she may pull through and on my birthday on a Sunday it was the most optimistic day."
"Then on the Monday we went in and the whole story had changed -- they called us into a room and just explained that this is exactly what is going to happen and it's not even a matter of days anymore. It might be hours. That was of course the most crushing time of my life," says Mr. Cardoso.
"We lost some of our best staff. Dir./ Adadevoh had been working with us for 21 years and was perhaps one of the most brilliant physicians. I worked with her. I know that she was sheer genius," says Dr. Ohiaeri. In the Nigerian media, Dr. Adadevoh was praised as a heroine but her grieving son, at that time, found it hard to read the articles which he has now proudly collated in a folder.
"I'd had such a big loss [that] I was trying to close myself off from everything. So it was hard for me and then with time it became more and more apparent exactly what she had done," Mr. Cardoso says.
"By identifying the index patient it really helped Nigeria to prepare and get ready to trace everybody and I think that's the difference between us and our West African neighbours -- Guin-ea, Liberia and Sierra Leone," he adds.
Mr. Cardoso says the outpouring of praise for his mother fills him with immense pride and has softened the blow. "I wonder how one individual has so much connection with so many peo-ple. So, it's like we shared her with everybody which is special."
But Dir. Adadevoh's only child knows his country may not be out of the woods despite being declared Ebola--free. "People were very paranoid and in the last few weeks it has calmed down. I just hope with this news they don't let their guard down," he says.
A country home to 170 million, Nigeria has almost seven times the combined population of Guinea, Liberia and Sierra Leone. A rapid response and effective tracing of almost 1,000 indi-viduals who may have been exposed to the virus meant the number of Ebola deaths in Nigeria was limited to eight.
At the heart of the fight against Ebola in Nigeria was Dir., Ameyo Stella Adadevoh. Dr. Adadevoh diagnosed American-Liberian Patrick Sawyer with Ebola when he was hospitalized in Lagos. The doctor and her staff physically intervened when Mr. Sawyer tried to leave the treat-ment centre. This action cost Dr. Adadevoh and three medical staff their lives when they too con-tracted the disease.
Ameyo Adadevoh was a Nigerian physician. Her great-grandfather, Herbert Macaulay, is one of the most celebrated founders of modern Nigeria. Her grandfather was from the illustrious Adadevoh family of the Volta Region of Ghana to whom she was very much connected, though she lived in Lagos, while her father was also a physician and former Vice chancellor of the Uni-versity of Lagos.
She is credited with having curbed a wider spread of the Ebola virus in Nigeria by placing the patient zero, Patrick Sawyer, in quarantine despite pressures from the Liberian Government.
On 4 August 2014, it was confirmed that she tested positive for the Ebola virus strain and was being treated. Adadevoh died in the afternoon of 19 August 2014.
Nigeria is lucky that Mr. Sawyer ended up in the care of Dr. Ameyo Stella Adadevoh and
the team she led. I spoke to Ameyo Stella Adadevoh, the senior Consultant Endocrinologist and Physician, who has just died of the Ebola Virus Disease (EVD), to schedule a previously agreed medical review. It was a Saturday.
We agreed that I would come in the following Monday, July 21. On 20 July, Patrick Saw-yer, the index case now thought to have brought EVD into Nigeria, was admitted into the hospi-tal where Ameyo worked.
On 21 July, I attended the appointment as agreed. She had completed the rounds where she reviewed the cases, including Mr. Sawyer. She saw me shortly after mid-day. As always, it was professional and detailed. Unknown to me, Sawyer was already in the hospital.
Unknown to her, he was already terminally symptomatic with EVD. We managed on that day to do my review and, curiously in hind-sight, fit in a conversation about life, death and dy-ing. As she would herself later narrate with her Chief Medical Director, Dir. Benjy Ohiaeri, Mr. Sawyer, on admission "denied having been in contact with any person with EVD at home, in any hospital or at any burial."
So, on 21 July, Mr. Sawyer was being managed for Malaria. He had tested positive for Malaria parasites. It would take another day before the full possibility would hit home. By then, she'd probably already had fatal exposure to the virus. But, once she struck upon the possibility that Mr. Sawyer was EVD-positive, Ameyo "immediately isolated/quarantined the patient, commenced barrier nursing and simultaneously contacted the Lagos State Ministry of Health and the Federal Ministry of Health to enquire where further laboratory tests could be performed as we had a high index of suspicion of possible Ebola Virus Disease. We refused for him to be let out of the hospital in spite of intense pressure."
Her suspicions proved correct. That is Ameyo! If the occasion demanded it, she could be martial with care and sweeping in her command. She had earned her right to calibrated authority. The consequences could have been unfathomable if Mr. Sawyer had ended up in a General Hos-pital, for instance. It required someone with her capabilities and pedigree to be able to take the measures needed to firewall Mr. Sawyer and limit the contamination that he would have inflict-ed. For that, she paid with her life.
Ameyo became a doctor at 25. She had been my personal and family doctor for over 15 years. Her roots were both deep and grand. She is one of the few Nigerians the face of whose recent ancestor adorns one of our currency denominations. Her Great-Grand Father, Herbert Ma-caulay, is one of the most celebrated founders of modern Nigeria. Her father was himself a dis-tinguished physician, academic and university administrator of considerable distinction. Not that any of this mattered much to her.
When Ameyo qualified as a doctor in 1981, I was still a kid in High School. Yet, I could get away with calling her "Ameyo". To many of the children, she was "Auntie Ameyo". She simp-ly wanted to get things done, and done right.
That was important to her: doing things right. In her field, Ameyo took no prisoners and tolerated no half measures. If you came to her with issues outside her field, she knew the experts to. If you showed up hoping to get worshipped, you were in the wrong shrine. There was some-thing about her directness, professionalism, commitment to knowledge and curiosity, and irrev-erence that made Ameyo deserving of respect well beyond the calling of the cloth.
She loved her calling and was totally dedicated to it. When my kid brother died in June 2006, my Dad suffered terribly. She took charge of his management and inspired him to re-discover joie de vivre. While she battled for her life this past week and more, my Mum and Dad in Imo State joined in the legion of Nigerians who prayed and wished for a different ending. Like many people who had passed through her life, Dad's testimony is quite simple: "that woman saved my life!".
Nigeria is lucky that Mr. Sawyer ended up in the care of Dr. Ameyo Stella Adadevoh and the team she led.
A less able lead or a less dedicated team could have let itself and the country down. Un-like many of her peers, Ameyo didn't play god. Nor did she celebrate not having read any medi-cal journal after Medical School. On the contrary, she knew her specialty and invested heavily in being up to date with the latest journals and skills in it. She was always honest about where the limits of her skills lay and would happily refer cases to colleagues with the requisite specialty whether in or outside Nigeria.
She had one heck of a professional Rolodex! All of us who had the privilege of ever hav-
ing been managed or attended to by her would testify that this was a professional of exceptional thoughtfulness, ability, diligence, and application. The many colleagues whom she mentored or supported would too.
We've all lost an outstanding person, support, redoubt, and professional. Ameyo had one of the sharpest minds you'd ever meet. She was at home discussing experimental physics, molec-ular biology, public health, lip-stick, the science behind bra-sizes, or different genres of music. She loved life. She was the mother of a son whom she loved more than life itself and lived with a mother to whom she was devoted.
The void she leaves behind cannot be filled. They deserve our thoughts, care and prayers. Because of the circumstances of her passing, there may be no grave to memorialize Ameyo.
This is why we must give careful thought to how to do so. We must hold up and celebrate her example of selfless professionalism to the point of death. And, as a people, we must be grate-ful that someone like her is still in supply in our country. Ameyo always had the Hippocratic Oath hung in front of her on the left wall in her consulting room, just beside her certificate.
I once asked her why? She said if you don't believe in it you shouldn't be here. She died true to her oath and calling. Our country owes her a debt we can never repay. She was truly and exceptionally special.
MWAN joins the global community to commiserate with all who have lost family mem-bers and friends to the ongoing Ebola Virus Disease (EVD) outbreak. The toll on the healthcare workers in the affected countries has been quite high with Nigeria recently not being spared. MWAN has been hit with the death of one of our own, Dr. Ameyo Stella Adadevoh, a brilliant Consultant Endocrinologist, who died in active service to Nigeria, and in doing so greatly spared the nation from the widespread rampage that our sister West African countries are suffering from in this EVD outbreak.
The late Dr. Adadevoh was the first child of the late world renowned Pathologist. Prof. Kwakwu Adadevoh, who was also a past Vice-Chancellor of the University of Lagos, Nigeria. She is also the niece of the owners of Clina Lancet Laboratory and the Great-Granddaughter of our hero past, Sir Herbert Macaulay. On her own merit, Dr. Adadevoh was a Consultant Endo-crinologist per excellence, a quiet and diligent Clinician, beautiful lady and loving mother to one son.
We and all who now mourn the passing on of Dr. Ameyo should be comforted that she died a hero. She was the Doctor who entertained a high index of suspicion that Patient Zero was suffering from EVD and thus refused to let him leave the First Consultant Hospital in Obalende, Lagos, when he and others pressured her for his discharge against medical advice.
She promptly reported the case to the relevant Public Health authorities at State and Fed-eral levels and thus saved many lives by doing this. Though her death is so heartbreaking, we join her family and well-wishers to pray that her gentle soul rests in peace now.
OODDEE BBYY JJOOEE OOKKUUNNGGBBOOWWAA
Early this April, Lagos State Health Ministry and Commissioner, Dr. Jide Idris, appealed to all health practitioners to watch out for patients presenting symptoms of Ebola so that Nigeria would be delivered from the endemic disease already spreading through in Guinea.
The burly patient that she admitted on Sunday, July 20 had just flown in from nearby Monrovia, having cleared Airport screening for hidden weapons, hazardous materials, and illegal substances, with the might of ECOWAS bureaucracy beside him, a passport of the United States of America with him, and powerful Government connections behind him.
What Airport security was ill-equipped to detect, however, was an even deadlier national threat – the virulent etiological agent for Ebola! Hence, in his medical history, he conveniently ignored his recent contact with a case of Ebola, visits to any person infected with the virus in a hospital, or participation in a funeral of a person who died of the disease. All three criteria, it turns out, precisely described Mr. Patrick Sawyer's status vis-a-vis the late sister, Princess, whom he lost to Ebola, on 8th July.
In Dr. Ameyo Stella Adadevoh, an epidemic found its match that effectively stopped its incurable match of death. Obligations to the Hippocratic Oath of her noble profession compelled
the Senior Consultant Physician, First Consultant Medical Center, to do no harm but only good. Her august patient had just landed from endemic Liberia with distinctive symptoms; therefore, she summoned uncommon courage, ignored his denials, queried Ebola nonetheless, arranged for blood analysis, and skillfully turned his hospitalization into quarantine! By doing this, she stopped an Epidemic and saved a nation from a deadly virus.
As soon as his Test from LUTH came back presumptive positive, she promptly alerted Federal and Lagos State Health Ministries. In so doing, she identified the index Ebola patient on Nigerian soil, stopped nationwide spread of the virus, and saved a nation from an epidemic!
While she gave him medical care for his disease, he gave her medical disease for her care! But she patiently absorbed the impact of the infection that she contracted unwittingly without spreading it. In so doing, she saved her nation and averted a looming Epidemic that was not!
A private Clinic that relies on Corporate retainership and patronage of the affluent to get by, should not mess around with a VIP patient; but that, in a nutshell, is all she did by defying the petulance of a Liberian ECOWAS delegation that pressured her to discharge Mr. Sawyer to attend the "8th Joint Retreat of ECOWAS Institutions, Permanent Representatives and National Units". By denying him medical clearance to proceed to Calabar, she saved Nigeria from an im-minent Epidemic....
...Yes, with her very life, she made a supreme sacrifice but saved a nation from ominous Ebola epidemic! If ever a case or nominee for posthumous National honour is needed, CASE CLOSED...!!! Much Respect, many Thanks, and GOD bless the memory of Dr. Ameyo Stella Adadevoh!!
PPRROOFFEESSSSOORR CCLLAARRAA IIKKEEKKEEOONNWWUU
Woman of Substance, Consultant par excellence! You were one of the relatively few women to break the glass ceiling and walk majestically in a specialist terrain which for long in the African continent appeared to be the exclusive domain of the menfolk. You arrived there as a great achiever attracting the respect and love of even your male colleagues and all.
Your love for your country and indeed humanity made you risk your life to fulfill the Hippocratic oath in the unfortunate Ebola virus disease saga. Yes you eventually paid the price, but we will always remain grateful to God for a life like yours. Great life, suffused with love for humanity. Yes, we know how much resources and efforts go into the training of a doctor more so a consultant in medicine!
These are not lost though we would have loved to have you continue to render your im-peccable services to humanity but God knows best. Even within the relatively short span of life you made a huge mark. You will remain a pride to humanity in general and womanhood in par-ticular. Sleep on and take your rest in peace. We love you but God loves you more.
FEMI ONASANYA Yes, you fought a good fight, a rare one for that matter in a clime filled with greed and
self-centeredness. You were one in a million, a woman from the lineage of the then Moremi, in the old Yorubaland.
Dir. Ameyo Stella Adadevoh, you saved your country from the deadly Ebola epidemic that could wipe out millions of people within a short period and chose to give your life; your rich curriculum vitae and medical pedigree in substitution.
A Senior Medical Consultant is gone. A mother has finished her race! A great Nigerian is no more. Even though you ain't immortalized by the government in recognition of your bravery You will forever live on in the hearts of millions of Nigerians And our unborn children would also celebrate you.
EEffffiioonngg DDaavviidd
My heartfelt condolence to the family of late Dir. Stella Adadevoh...she remains a woman of great courage, a true amazon...who has given we young Nigerians hope for the future...that the right things can be done at the right time...may your gentle soul be in perfect peace and eternal happiness...also, I pray that God gives your family the fortitude to bear the loss...and may his grace always be with them...Adieu...Adieu to a wonderful human being!!!
NNjjiiddee NNddiill ii
When I heard that Patrick Sawyer, the Ebola carrying patient was taken to 1st Consultants, I was not surprised. He was taken there for a reason, good quality care was guaranteed! For this reputation, you paid a price Ameyo... I had only know you intimately for about 6 months and within that time, I knew that you were a gem, an honorable woman, a doctor different from the rest. You keep your side of the deal always.
We have been strategizing and collaborating on a confidential project to make 1st Con-sultants more accessible to more patients of all income levels and class..... we spent months dis-cussing, with so many meetings and late night calls. Even up to the point when the hospital was shut down by Ministry of Health following the death of Patrick Sawyer, we spoke and we were planning a meeting when I stopped hearing from you.
Never in my wildest dream did I realize you were the very Doctor who treated Sawyer.... My calls to you went unanswered until I sent you text asking if you were okay? Your response to me was an email with the press release detailing the events with the Ebola victim and how you struggled to keep him from leaving the hospital and spreading the disease.
Your action was selfless and only God can reward you for the sacrifice you made for us Nigerians.... I am still in shock following the news of your death yesterday.... We are all on earth for a reason and when our time comes and our mission is done, we depart. You have accom-plished your mission Ameyo and gone on to a better place.
My heart goes out to your family for they have lost a precious woman, wife and mother. I only wish I had known you earlier and longer but I am sure we will meet again in another life.
IIkkeennnnaa GGeeoorrggee IIkkeennnnaa
part from the Savior, who is Christ Jesus, There are little saviors that live among us, Saving us from bacteria, fungi, and virus; Some of them lay down their lives To make sure that humanity survives; Some are women, some are wives; Some know the risks they take, That, sometimes, life is at stake; Some take the plunge all the same, And earn themselves eternal fame; Greater love has no one than to die In answering a heart's call and a neighbor's cry; There is no greater love than that this living soul Saved her country from Ebola's sheol; Saved her people from Patrick Sawyer Disease; Saved you and me from that deadly breeze; Our highest honors and praises are her due; Dir. Ameyo Stella Adadevoh, adieu; Adieu, Great Soul; adieu.
SSaammuueell CChhuukkuu
I heard you had been discharged, and then this morning as I looked through my phone to catch up on the world, I read you are gone. I just wish I could choose which to believe.
I never met you but I know you have affected my life tremendously. If Mr. Sawyer had passed through your scrutiny as he did airport security with diplomatic apparachik, I probably would have been at risk. After all, I commute by public transport most of the time and like most Nigerians, I mingle in the crowd in a bid to make ends meet.
And so I thank you Doctor. I and millions of other Nigerians will never forget you, your memory will continue to resonate just like that of your forebears. Thank you for insisting on best practice when others would have buckled under pressure. I know that you feel no more pain where you are and that a host of angels wait to take you to rest. You will never be forgotten, even in a country like ours. Fare thee well.
LLaaii OOmmoottoollaa
The story of Dr. Stella Adadevoh should be a classic case study in Medical schools around the world, both Nollyhood and Hollyhood have one of the most inspiring movie of all time at their door steps.
Oh death! who would have expected you on this path. We as Nigerians should dedicate today as a memorial, words can not explain the sacrifice this God fearing and exceptional woman have made. I doubt if she's a Nigerian nevertheless she is. She will stand exceptional in the ca-nals of history as an extra ordinary Nigerian even if the Government will not honour her.
OOttii OObbiilloorr
You were an embodiment of courage, kindness and love You gave your all that others may be spared the agony You paid the ultimate price because you would not abandon your patient even in the face of danger Your Christlike nature overwhelms us Your sacrifice will not be in vain Fare thee well our hero Goodnight our warrior Rest in peace our angel. #MuchRespect
OOkkoorroo UUddeennssii LLii ll iiaann
Words can't describe the shock I experienced when I read the news online of your death!! At first, I debunked it off as a rumour but as the news began to gather authenticity from key health players, I had to believe and accept it as true.
I left fcmc over a year ago but the 2 years I worked there was a great experience for me because I learnt a lot from your wealth of knowledge, you were truly a consultant par excellence. Your diagnosis were almost always 100% accurate, I'm not surprised it was you that nailed this Ebola down and in good time too!
We thank God for your competence. Your death is a huge sacrifice to save many millions of Nigerians, you practised your professional calling to its core essence-sacrificial service to hu-manity!! You will never be forgotten Ma! Your legacy is permanently imprinted upon the sands of time...never to fade, adieu great woman, we respect you!!
PPaauull OOllaalleeyyee
Farewell to an Eminent Endocrinologist, Passionate Physician, our own Mother Theresa! We salute you and praise your heroic professionalism. Take a well deserved seat amongst the company of Angels and Saints in heaven. We will continue to pray for your family, friends and colleagues; to have the courage they need at this time. But when the dust of Ebola finally settles, we hope that the authorities in Liberia and Nigeria will for ever be grateful and immortalize your contributions with a medical institution in Monrovia and Lagos.
FFeemmii SSoowwoooolluu
Too far away In another space we stay Imagined reality Warped realism A dangerous game we play Lonesome lives of self deceit Pretend self belief Easy to forget From whence we came We live the movie ...A tragi-comedy Of sorts... Toy soldiers Tin men Cartoon characters With puny hearts
Evil minds Soiled hands Tainted souls And smelly clothes...! Our angels have fled Or just die in our hands Devils in their stead ...But, only the dead Bury the dead... She saves But she dies Healing hands Heal no more A diadem of silky soft petals For our heroine Roses, and Peonies Violets, and Tulips Fresh fragrances for Lady Ameyo Diva exemplar For she glows From enchanting lights above From the bosom of God A new saint, behold. Adieu.
MMaaxxwweellll NNaakkaannddaa
My dear Doctor, truly you did your best to avoid the wide spread of Ebola virus in our country not minding the pressure to bury the ethics of the job as at that material time. I really un-derstand the pains your family members and loved ones are passing through but the fact remains that you have proved a point for your generation and the generation to come that being fair at work is key and each time I look at your picture,
I see the spirit of a true leader and mother of our time. May God Almighty grant you eter-nal rest and I equally wish your husband, children and other well wishers the fortitude to bear this irreparable loss. ................. Adieu Our Doctor!!!!!!!!!!!!!!
IIkkeennnnaa GGeeoorrggee IIkkeennnnaa
Nationalism runs in the blood. You know Herbert Macaulay, Nigeria's foremost national-ist, the man whose face is imprinted on the one naira coin? He was the great-grandfather of Dr. Ameyo Stella Adadevoh, the woman medical consultant who led the medical team that treated that Liberian merchant of death, Patrick Death Sawyer.
She STOPPED Sawyer from leaving the hospital when she confirmed that he was carrying the Ebola virus. Even when intense pressure was put on her to allow the Liberian to proceed with his devilish trip to Calabar for a useless summit, Dr. Stella Adadevoh refused to discharge him, knowing the risks he posed to the Nigerian society.
Some doctors would have quickly discharged him as soon as he was confirmed to be Ebo-la positive, for their own safety and for the safety of their hospital staff. Some would have re-leased him if the pressure became unbearable. Some wouldn't have even bothered to test for Ebo-la, while others would have been contented with treating malaria, after which they would unleash that death merchant on the Nigerian people.
But this woman, this courageous and selfless woman, RESISTED all pressure to discharge Sawyer and decided not only to test and treat, but also to quarantine him and prevent further spread of the virus. Had Dir., Stella Adadevoh discharged Patrick Sawyer, which she could have done so easily for her own safety, Ebola could have been ravaging Nigeria by now. But she said NO. She assumed the responsibility to protect you and me from Patrick Sawyer and his deadly disease.
She assumed the responsibility to protect her nation. She put the life of her compatriots ahead of her own. Aware of the risks involved in treating an Ebola patient, she did not run. She refused to run and rather preferred to shed her own nationalist blood for the sake and survival of you and me. She is my HERO, our HERO.
I learnt that this great woman became a medical doctor at 25. And that she always "had the Hippocratic Oath hung in front of her on the left wall in her consulting room, just beside her certificate." I have immortalized her in my heart. But we can do more. A federal university teaching hospital should be named after her.
Or better, her face, like her great-grandfather's, should be imprinted on the Nigerian cur-rency. At least, let her be the first Nigerian woman to adorn our currency with her beautiful face. She deserves more. Adieu, Dir. Ameyo Stella Adadevoh. Thank You.
KKoollaa GGbbaaddaammoossii
Dir. Stella Shade Adadevoh, I had known you for 21yrs and within that period, I knew that you were a gem, an honourable woman, a sister, a friend, and a doctor different from the rest. You kept your side of the deal always just the way you made sure I stopped smoking.........
Had Dir. Stella Shade Adadevoh discharged Patrick Sawyer, which she could have done so easily for her own safety, Ebola could have been ravaging Nigeria by now; but she said NO. She assumed the responsibility to protect you and I from Patrick Sawyer and his deadly disease.
She took on the responsibility to protect her Nation, put the life of her compatriots ahead of her own.. Aware of the risks involved in treating an Ebola patient, she did not run. She refused to run and rather preferred to shed her own nationalist blood for the sake and survival of all Ni-gerians.
A saviour indeed you were. You remain my HERO, an embodiment of courage, kindness and love, a true Amazon, a RARE GEM. You are my dear friend. You gave your all so that oth-ers may be spared the agony. You paid the ultimate price because you would not abandon your patient even in the face of danger.
Your Christ like nature overwhelms us .no greater love than this. With your very life, you made a supreme sacrifice but saved a nation from the ominous Ebola epidemic! Your sacrifice will not be in vain, your action was selfless and only God can reward you for the sacrifice you made for us Nigerians.... I am still in deep shock following the news of your death....
Fare thee well our hero, SIS as I fondly called you. You will forever live on in the hearts of millions of Nigerians Dir. Ameyo Stella Adadevoh, adieu; Adieu, Great Soul; adieu.
EEmmmmaannuueell && IIffeeoommaa EEzzeekkwweerree
She was a caregiver And a compassionate one too She was a mentor Who loved to give and to care She has left us nestled in the grief of those she shielded
To you, noble one (and to the valiant throng) All we have to say is this: Thank you, Well done, And farewell.
AAbbiimmbboollaa OOkkuullaajjaa
Anselm Odinkalu spoke the mind of some of us in his tribute, but I will add mine. My wife and I have been so devastated. Ameyo was our personal physician. It is very difficult to im-agine that she is gone.
On Thu, 31 Jul 2014 07:23:10 I sent an email with the subject: Just Checking - "Good morning Doctor, We follow the Ebola events online from the USA, and in particular the joint statement issued by FCH. We are concerned and just checking to make sure that you are fine and that the situation is under control. Very Best, Abimbola & Busola"
In her usual manner, she responded almost immediately July 31, 2014 at 7:48:50 AM EDT "By God's Grace, we are all well at the hospital. Thanks for your prayers and support. God bless"
You were a thoroughly amazing woman, thoroughbred professional and you were the on-ly female physician that I know who men lined up to consult. It is either Ameyo or nobody. You
were indeed the life wire of First Consultant Hospital. I personally had not consulted with any physician my entire adult life apart from you.
My entire family was silently praying for your miraculous recovery and when your pas-sage was announced, I sobbed. It is remarkable that you saved the lives of so many people but gave yours for the sake of the nation.
I fell ill at some point in 2011 but God used you to rescue me. You arranged for me to go to another location for tests and more tests to narrow down on the treatment. When I recovered, you asked me to call the cook and you instructed her on how to make sure that Ugu ( a vegetable delicacy ) was always part of my meal, and how it should be cooked. I never knew anything called Ugu prior to that time.
You were the personal physician to my parents-in-law and they indeed broke down on hearing the news about your passing. At some point I brought my mum to consult you before she passed on. You had grace, you had charm and was always doing so many things at the same time. Consulting, talking to one elderly relative peeping though the door to say hello or to get free consultation, or talking to someone on the cell phone to give free consultation. You were always surrounded by so many young doctors eager to learn at your feet.
You took my son at some point, at such short notice to shadow you. We had similar plans for him this holiday but this did not work out. When my mum was terminally ill and had to be brought back to Nigeria, you showed interest and gave me a list of medical needs to bring along to take care of her, and when she passed on, you wrote a beautiful consolation email to me.
We need to keep in mind that in the midst of decadence and rot in the health care system in Nigeria, you stood out. When my family received the initial false news that you had been dis-charged, we all held hands together and were jumping in celebration. Moods changed when it turned out that the news was false and a few days later you bid us goodbye.
Judging by all the moving tributes, I have no doubt in my mind that you are resting at the foot of The Lord. May God grant you eternal rest, and comfort your son and all the loved ones that you left behind to mourn you.
Adieu our dear doctor AMEYO.
AAbbiimmbboollaa OOkkuullaajjaa
I have not seen Ameyo in 30 years since med school. Her ageless beauty and her superior intelligence would remain ingrained in my memory for ever. I cannot forget how she would carry her Grey's Anatomy Text with such admiration and determination. My respect for Ameyo as one of the most likely to succeed in medical practice never wavered.
The way and manner she conducted herself during this epidemic has further endeared her to the hearts of those of us that were fortunate to meet her at some point, and the countless Nige-rians that never met her. Ameyo was a physician to the core. She saved the Nation. If only we could reverse this tragedy, we would pay any price to keep you with us. But then, God has other plans. Ameyo, for all your sacrifice to save the Nation, your place in Nigeria history is assured. Good night
WWiissddoomm && RRoossee DDaaffiinnoonnee
If anyone can truly measure, Devotion, Passion, Compassion, and Commitment; then, DR. AMEYO ADADEVOH, was a colossus, an indisputable "Class Act" on her own!
Her infectious personality and disarming smile, compel and attract, albeit ineluctably, to a SOUL enamored and imbued with an unquestionable professional excellence and ethos.
It was therefore, not surprising that her colleagues and friends drew national attention to her deteriorating condition and plight, which compelled the relevant authorities to raise the BAR of professional performance and expectations; ennobling our hearts with the Latin aphorism, "Quae nocent, docent- what pains us, teaches/trains us'!
DR. AMEYO STELLA ADADEVOH exemplified in her illustrious but brief life, that the "very best" is still possible and present in us, in spite of our collective doubts, and denigration. Therefore, as a consummate professional and true Patriot, she epitomized the rare gift and Spirit of sacrifice and love, granting us an imperceptible glimpse of our humanity and God-endowed greatness as a People, which we must harness, as recompense, for such an irreparable loss! ADIEU!!!!! Rest in Perfect Peace!!!!
ABOVE: proposal for a memorial pillar located at the point where the three most heav-
ily Ebola hit countries, Liberia, Sierra Leone and Guinea, come together.
IIffoogghhaallee EEjjeettaa
When someone we love dies, we never get to see them again but we will always feel them, because they live on in our hearts and our memories in our smiles and our tears and even though we can't touch them, we will never forget how they touched us.
The death toll wrung up by this Ebola epidemic in the group of health care professionals tasked with caring for their afflicted fellow men, is appalling as it is unnecessary. This small co-hort of Ebola fighters has been more than decimated.
Need to honor these true heroes of mankind, many of whom are, presently, unknown out-side their small rural worlds. My proposal is for the construction of an elegant memorial bearing the names of all those who died, to be constructed on the site of three corners.
The next to segments focus on the how the veraties of Ebola virus infection, and the be-havioral changes necessary to prevent contagion, are targeted on the most basic of human in-stincts. The second story about Kaizer is unforgettable. The segment immediately below ties this topic in with the outstanding, evocative photographs made by John Moore who has rendered a service to mankind through his work in Liberia.
WWEESSTT PPOOIINNTT,, AAUUGGUUSSTT
In the West Point slum of Monrovia, Liberia, at a holding center for those suspected of but not yet confirmed as having Ebola, photojournalist John Moore witnessed a man stagger, fall and hit his head on the floor. The man's wife was with him, but because of the highly contagious na-ture of the Ebola virus she could not reach down to embrace him, even touch him, without risk-ing infection herself. She was left helpless, unable to do anything but stand over him. "It was es-pecially hard on the eyes to see," Moore says.
Similar scenes play out with cruel regularity in West Africa as family members caring for loved ones suffering from Ebola weigh self-preservation against the basic human desire to touch and hold a loved one in mutual comfort and compassion. The Ebola virus is spread through con-tact with the blood, sweat, and other bodily fluids of those already ill from the disease. That makes the direct, hands-on contact we equate with tender loving care highly risky.
In addition, because touching the body of someone who has died of Ebola can also trans-mit the disease, various traditional Liberian burial customs (which include washing and laying hands on the body) have had to be curtailed, which has led to further emotional anguish.
One of Moore's most visceral photographs depicts a woman crawling on the ground to-ward her dead sister as members of a Red Cross burial team, clad in white protective suits, carry her away on a stretcher. The surviving sister is seen, in a wrenching gesture of farewell, trying to
throw dirt onto the covered body as it passes by. "She just collapsed on the ground" afterward, Moore says. "It was devastating."
And no wonder. The inability to reach out and touch loved ones in situations that would naturally demand physical connection is part of the ravage of Ebola, says Cynda Rushton, of the Johns Hopkins Berman Institute of Bioethics and the School of Nursing. "People are left with witnessing the suffering, and there is a profound sense of helplessness. It threatens people's sense of integrity: How can I be a good parent or wife or son or husband if I cannot express my love in this very fundamental way?"
In the case of Ebola, however, patients fighting for their lives can be incapable of any in-teraction, leaving touch as seemingly the last way to communicate love and care. "Everyone re-lies on a network of family and friends whenever they go through a stressful situation, and obvi-ously illness is one of the most stressful," Chino points out. With the stringent dangers of touch posed by Ebola, "we're asking people to overturn all of their instincts because of the risk."
"Even when they are at their lowest point, fighting for survival, patients can still sense the presence of loved ones," says Dr. Isidore L. Berenbaum, a psychiatrist at Boston Medical Center.
"The patient is well aware of that glance, that look, that voice," he says, "The patient feels safe, and that is the key thing." And when they recover, they will remember that."
Days after Kaizer Dour died of Ebola at the edge of a mangrove swamp, strangers carried his rotting corpse in a dugout canoe for a secret burial. Out on an uninhabited, bush-covered is-land, far from the national basketball court where Kaizer won acclaim as one of Liberia's most valuable players last season, the strangers fulfilled one of the most important duties of a Liberian family -- burying the young man.
One of the men stood knee-deep in a shallow grave, shoveling sand over Kaizer's 6-foot-2-inch body. The other, having steeled himself with swigs of a local gin called Manpower, gave a speech to bid Kaizer farewell in the absence of mourners.
"Your whole entire family, no one is here to represent you," the man intones, captured in a cellphone video. "Your mother gave a rose that we should bury with you to remember her. She tried her best, but she was alone."
The burial, one of countless unlisted deaths in the deadliest Ebola outbreak in history, was an anonymous end for a middle-class young man on the cusp of celebrity. A rising star in Libe-ria's top basketball league, Kaizer, 22, had dreamed of making it to the Los Angeles Lakers, the home of his idol and fellow shooting guard, Kobe Bryant. His Facebook profile, updated just three weeks before his death on Aug. 9, shows him spinning a basketball, an overhead light beaming down on a face bearing a young man's self-assuredness.
A proper burial surely would have drawn hundreds of people -- teammates, friends, fans and members of his large family, for whom Kaizer was an enduring point of pride. But this strange, horrific disease called Ebola, new to this part of Africa, had already started dismantling his unusually tight family, bringing fear, anger and ultimately death to the people who cherished him.
Ebola is a family disease, Liberians are reminded continually in Sunday sermons. The more families pull together to fight the virus, the more they seem to fall apart. Kaizer's extensive family had survived Liberia's 14-year civil war, growing stronger as it united against poverty, rapacious rulers and indifferent governments. So when Kaizer got sick, his mother, Mamie Do-ryen, did what the Doryens had always done, turning to her family to help with her ailing son.
Kaizer, infected by his father, soon passed the virus to two aunts. In all, seven members from three generations died in quick succession. His mother, the family's dominant figure, sur-vived. But blamed for the calamity, she went into hiding, a pariah in her family's hour of greatest need. The family's center could not hold.
"Ebola was like a bomb," one of Kaizer's uncles said. This destruction of families is the central tragedy of the epidemic. On a continent with
many weak states, the extended family is Africa's most important institution by far. That is espe-cially true in the nations ravaged by the disease -- Liberia, Sierra Leone and Guinea -- three of Africa's poorest and most fragile countries. Ebola's effects on the region, in undermining the very institution that has kept its societies together, could be long-term and far-reaching.
Even today, as help increases from the United States and other nations, many victims in the region are still being treated within the family, a place of succor -- and a font of contagion.
"They were together, a strong family, but this Ebola broke the entire family apart," said the Rev. James Narmah, a Pentecostal minister who knows Kaizer's family. "That's what's hap-pening right now. Ebola is bringing a lot of divisions, a lot of hatred, inside families and inside communities, everywhere."
Kaizer's maternal grandparents, Joseph and Martha Doryen, had five sons and five daugh-ters. All survived Liberia's civil war from 1989 to 2003, a brutal one even by the standards of African wars of that era. Before the fighting started, when rebels tried to oust the military dicta-torship, Joseph Doryen worked as a driver at the agriculture ministry and then for a rich Ghana-ian businessman. After the businessman fled the war, Joseph Doryen began growing potato greens in his Monrovia neighborhood, Capitol Hill. The children helped, and his wife sold the crop at a local market.
Until Joseph Doryen died three years ago, the old couple could often be seen strolling or sitting together under the mango tree behind their home. Their 10 children were all "same father, same mother," a rarity in a large family of that generation. They were also comparatively fortu-nate, escaping the rockets that frequently rained on Capitol Hill, destroying houses and killing residents.
Like its American model in Washington, the neighborhood derives its name from the nearby Capitol Building -- one of the many ties between the United States and Liberia, a country founded by freed American slaves in 1822. But being next to Liberia's seat of government made the neighborhood a frequent target.
Not even the war, however, was as bad as Ebola, the family said.
"Even when we were fighting war at that time, you know the safe place to go," said An-thony Doryen, 39, the second-oldest son. "This one, you can't even know where to go."
"Ebola is a disease that eliminates families," he added. "It makes you afraid because when you get around your family, apparently you get in contact with it. It makes you go far away from your family."
Today, Capitol Hill's dirt paths snake around houses with corrugated roofs held down by heavy rocks. To the east, the Temple of Justice peeks above the palm trees. The president's Ex-ecutive Mansion is a quick walk to the south. The Liberian flag outside government buildings -- red and white stripes, with a white star in a blue box -- can easily be mistaken for the American flag.
For the Doryens, postwar Liberia led to better lives. Like most residents, they still got their water from aging, unsanitary wells. But because they had property in Capitol Hill, they were better off than most, with steady jobs as gas station attendants, government cafeteria work-ers, cellphone-card salesmen and market traders.
Just as they had during wartime, the Doryens pulled together during peacetime. The chil-dren built separate houses near their parents and tore down the flimsy old family home, pooling their savings to build an eight- room concrete dwelling. It offered stability, cohesion -- and a ref-uge for an ailing Kaizer.
For most West Africans infected during the outbreak, the virus was transmitted quietly, through tender acts of love and kindness, at home where the sick were taken care of, or at a fu-neral where the dead were tended to. But for Kaizer's father, Edwin Dour, Ebola came violently on the night of June 25 after a gravely ill man -- Patient Zero to the Doryen family -- was brought to the beleaguered government-run clinic where Kaizer's father was the chief administra-tor.
Six of 29 employees at the clinic died within a month of Ebola's arrival. Kaizer's father, known for never turning away patients, became infected, too, passing the virus to his son in a pattern seen across the city. The sick brought Ebola to defenseless health centers that in turn of-ten helped spread the virus.
Despite the money that the United States and other governments had funneled into Libe-ria's health care system in recent years, health centers quickly crumpled. The 16-year-old girl who had brought the disease from Sierra Leone to Monrovia died in the state-run Redemption Hospital on May 25. A doctor and five nurses there, working without gloves or the basics of in-fection control, died in rapid succession.
Though Redemption often did not have running water, it was one of the biggest medical centers in Liberia. So after it was closed in a panic in June, the sick scattered to nearby clinics, including the one managed by Kaizer's father. They were even less prepared to deal with Ebola's onslaught.
On June 25, a yellow taxi dropped off a young man in front of the clinic's gate. The pa-tient, a church caretaker, had apparently become infected when an old woman with Ebola was brought in for prayers. By the time the caretaker showed up at Kaizer's father's clinic, he was ex-hibiting the full-blown symptoms of late-stage Ebola: vomiting, diarrhea and -- a peculiar sign of Ebola -- uncontrollable hiccups.
Around 10 p.m., the sick man became violent and confused. "He was fighting -- unstable -- he was just going up and down, coming down on the bed, turning this way, that way," said the physician assistant on duty, Moses Safa.
The guard held the man down. "Then he gave up the ghost," Mr. Safa said.
The guard himself would soon die of Ebola, though not before transmitting it to Kaizer's father. The clinic's medical staff, terrified by the deaths at the state hospital, offered the ailing guard minimal care. Kaizer's father was not authorized to provide care, but he volunteered to put the guard on an intravenous drip -- and was infected in the process.
Kaizer's father tested positive for Ebola, but the government did not tell his family. In the-ory, workers are supposed to inform families of test results; in practice, few tests have been car-ried out and the results rarely provided -- another systematic failure that has contributed to Ebo-la's spread.
Kaizer's father, who was in his mid-40s, died July 23. Because his parents had separated years before, Kaizer helped tend to his dying father. But as has been the case for thousands who have died during this epidemic, the natural inclination to care for a loved one would prove his undoing.
On Aug. 9, Kaizer's father was laid to rest at Good Shepherd Funeral Home in a closed coffin. Though the funeral hall could hold 100 people, only about 20 came, mostly workers from the clinic and friends from the father's days as a soldier in the Liberian Army. No family member came.
Overwhelmed by Kaizer's illness, Mamie Doryen had brought him by taxi to her family in Capitol Hill. As day broke, the neighbors learned that an ailing Kaizer had been carried in over-night. Fear spread quickly. The neighbors, who knew that Kaizer's father had died, lived in close quarters and shared a well with the Doryens.
It was early August, and the government, reeling from the deaths at Redemption and other health facilities, was paralyzed. Many Liberians remained deeply skeptical of Ebola's very exist-ence, suspicious of government corruption. The government slogan -- "Ebola Is Real," written on billboards and posters -- merely reinforced the popular belief that it was not.
Still, enough deaths had occurred in the capital that, for many, any illness immediately caused suspicion of Ebola.
"We, who had family around there, were getting afraid," said Teddy Dowee, 21, a friend of Kaizer's and the Doryen clan. "I was afraid."
It is perhaps a peculiarity of the psychological response to Ebola that people outside an af-fected family, like the Doryens' neighbors, were often better able to grasp the reality around them. Those inside the family often wrapped themselves in layers of denial, as impermeable as the protective suits worn by health care workers. They denied Ebola's presence in the family to avoid being ostracized -- and to convince themselves that they could tend to a sick loved one.
They often had no choice: Throughout the Ebola hot zone, the chronic lack of treatment beds for months forced families to care for the sick at home. And so Mamie denied that Ebola had killed her former husband, Edwin Dour, and sickened Kaizer. Instead, they had both been poisoned, she insisted, telling her family of a mysterious woman in black terrorizing Kaizer in his sleep.
Some of those closest to Mamie accepted the poisoning story, a widespread belief in Libe-ria. They had reason to put faith in her. She was the family anchor, a woman of about 40 whose real name was Yah but was always called Mamie because she acted like a mother to her younger siblings.
So the family allowed Kaizer to stay, sharing one room with three family members -- all
of whom would die. The neighbors demanded that the Doryens take Kaizer away, threatening to call the authorities. But the poisoning story gave the psychological room for his relatives -- caught between their love for him and the fear of Ebola -- to take care of him.
One morning, Tina Doryen, an aunt tending to Kaizer, took a bath using a bucket in which he had previously vomited. "If that Ebola want to kill me, let it kill me," she said, Mr. Dowee re-called.
With Kaizer's condition worsening, the Doryens finally took him outside -- to a nearby church that was holding a two-week revival. It was already dark and the reverend, Mr. Narmah, was wrapping up a sermon on hope when the double doors of the church opened suddenly.
Kaizer staggered in, his large frame supported on either side by his two favorite aunts -- Tina, 20, and Edwina, 24. With Ebola in mind, the reverend instructed the aunts, both members of his church, to stay at the back with Kaizer.
"He had no strength," Mr. Narmah said. "He couldn't talk."
The congregation gathered around Kaizer for a prayer. Mr. Narmah poured anointing oil on Kaizer's head. He told the members to stretch their arms toward Kaizer but to not touch him.
Kaizer's family took no such precautions. To Martha Doryen, 29, another aunt, Kaizer was the kid nephew who had always asked her for a treat or pocket money. This year, seeing Kaizer play basketball for the first time -- and play so well that a fan handed him $50 after the game -- Martha realized with pride that he was "no small player."
"They were afraid of Ebola," Martha said of the church members. "It was my sister's only son. How can I be afraid? I can't lie. I touched him."
The Doryens' neighbors stepped up demands that Kaizer leave Capitol Hill as soon as pos-sible. The Doryens acquiesced, telling Mamie to take her son.
Kaizer died the next morning in his mother's home next to the swamp. No one from the family, except his grandmother, went there to help.
"We were angry and also afraid," said Kaizer's uncle, Abraham Keita. Mamie continued to insist that Kaizer did not have Ebola. Perhaps because of her assur-
ances, five church members joined around her son's deathbed. As Kaizer lay dying, he said he saw the woman in black who had been beckoning to him in his troubled dreams. He could no longer hide from her, she told him, as those gathered around him prayed loudly in tongues.
Abruptly, Kaizer reached for his neck.
"He said he saw the woman, the spirit, standing over him, choking him," said Rose Mom-bo, a church member there. "He was fighting."
Kaizer, his eyes wide open, burst into tears, spat out something and died. It happened just as his own father was being laid to rest. During the funeral service for Kaizer's father, the scat-tered attendees learned that Kaizer had died as well.
The government was still incapable of responding in the most basic ways, including col-lecting the highly infectious bodies of the Ebola dead. So two days after Kaizer's death, the stench of his corpse seeping out toward her neighbors, his mother asked one of them, Jerome Mombo, to bury her son.
Mr. Mombo took precautions against Ebola, adding $15 of his own money to the $55 in American currency Kaizer's mother had given him. He paid fishermen $60 and spent the rest on chlorine, a spray gun, six empty rice bags to sew together as a burial shroud and bottles of Manpower.
The men drank the gin before entering the room, then again inside. "Otherwise, I couldn't do it," said Mr. Mombo, who later delivered the brief farewell for Kaizer. "I had to drink some-thing to give me more power."
Heavy rain allowed the fishermen to paddle all the way to a flooded area behind the home of Kaizer's mother. Tony Kaba, 22, a basketball player and friend of Kaizer's, stood at a distance and watched the men take the body away.
"There was no family," he said.
It took half an hour down the Mesurado River to reach Kpoto Island, one of many unin-habited islands up a channel called Creek No. 2. With soft, sandy soil, Kpoto has long been used
by the poor to bury their dead. Now, freshly dug graves are obvious in the thick bush.
Many relatives of Ebola victims are believed to have carried out secret burials across the region because bodies are simply not picked up in time, or the families do not want to surrender relatives for mass incinerations. Such burials are believed to contribute to a significant under-count of the Ebola dead in Liberia, Sierra Leone and Guinea.
For Kaizer's team, the Timberwolves, his death upturned the future. It had planned to build the franchise around Kaizer, who seemed destined to become the top player in the Liberia Bas-ketball Federation, said Jairus Harris, the team's vice president.
Kaizer was fast, shot well and fearlessly challenged any opponent. Over the years, two Li-berians had come close to playing in the National Basketball Association in the United States, a source of pride for Liberian basketball.
"Kaizer would have made it in the N.B.A.," Mr. Harris said. "I'm sure." Instead, his mother returned alone to Capitol Hill, seeking the comfort that the Doryens
had always provided one another. But things were different this time. The consequences of the family's rallying around Kaizer were quickly becoming clear.
Kaizer's two favorite aunts, the ones who had held him up in church, died on the same day, Aug. 27, less than three weeks after he did. Kaizer's grandmother and a cousin were visibly sick, too. Some of Kaizer's uncles had fled Capitol Hill. The remaining Doryens gathered in a daze
"It was a scene to behold," said the Rev. Alvin Attah, who has known the family for dec-ades. At the pastor's urging, Kaizer's grandmother boarded an ambulance to a treatment center.
Blamed for bringing Ebola to Capitol Hill, Kaizer's mother could not return to her family home. She wandered toward her church half a mile away and knocked on the homes of congre-gation members, searching for a place to spend the night.
"But they refused to let her in," said Felicia Koneh, a family friend. "Everybody was afraid. No one knows where she went after that."
"It's pathetic, you know, to see a family just fall apart," she said.
Ebola is an insidious disease. It turns compassion into a danger. It turns survival into a haunting source of guilt. Kaizer's cousin, Esther, 5, the daughter of his beloved Aunt Tina, was clearly sick. On the day Tina died, Esther's father faced the anguish of going to see his ailing daughter in Capitol Hill -- but being too afraid to get close enough to comfort her.
"She tried to get to me, but I stood at a distance," said her father, Lester Morris, 27, who had separated from Tina this year. "I told her to go to her Auntie Julie."
The guilt and pain of trying to protect himself was wrapped in a tight knot inside him, a feeling shared by many other survivors.
"To see a loved one separated from you, you talk on the telephone and say, 'I'm dying,' and you cannot go -- it's more painful than the war," said Lester's father, Joseph Morris.
It is a comparison heard often, one that may seem extreme. The war killed perhaps a quar-ter-million Liberians, Ebola only 2,800 officially in this country so far. The war's destruction of Monrovia can still be seen in its broken roads, schools and buildings. Ebola has left no physical scar. But to many Liberians, the pain of Ebola is greater. Often, the only sure way to survive is to abandon one's family.
Esther's father and uncle begged the government for help. The family repeatedly called its Ebola hotline to get her out of Capitol Hill, but received only empty promises. It was late Au-gust, and the government was panicking. It had deployed soldiers to quarantine Monrovia's larg-est slum, setting off deadly riots. The cost of paralysis by the international community was con-tinuing to mount.
The Doryens worried that Esther would infect them, as Kaizer had. On Aug. 31, one of the remaining aunts, Julie Doryen, guided the girl with a stick to the main road outside Capitol Hill. Esther collapsed on the sidewalk.
A large, angry crowd watched from across the street, drawing the police and, finally, an ambulance. Esther, who had appeared dead, stirred to life. Her father, Lester, arrived minutes after she was put inside the ambulance. She was taken to an Ebola treatment center. Her father and uncle visited and thought she was doing better.
Before visiting again, Lester looked wistfully at a Christmas card from last year. In it, wearing a red dress with a big white ribbon, Esther stands against an idealized American back-drop of a colonial house, a green lawn and a white picket fence.
Overnight, her uncle received a call from a friend inside the center. Esther had died. He did not tell Lester. On the taxi ride there, Lester began to suspect his brother was hiding some-thing. By the time they arrived in front of the center at 10:30 a.m., Lester was yelling at his brother. Lester paced back and forth, his eyes reddening.
"He's weeping," said a man nearby. "Maybe somebody dying?" said another. "Brother, you gotta be a man," a taxi driver said. "Be a man, yeah? Don't be crying."
Lester did not cry inside the center when told about his daughter's death. He said nothing. His brother asked for the body for a proper funeral, or at least a photograph. Neither was possi-ble.
The brothers went to Capitol Hill to inform the Doryens. The remaining family gathered outside. Martha Doryen, Kaizer's aunt, started wailing, throwing her hands in the air. There were no tears, but the sound echoed throughout Capitol Hill.
With no body to bury, Lester could not meet his traditional duties. Suddenly, he started crying, uncontrollably, tears streaming down his face. The women, and his brother, looked away.
Within hours of the death of Kaizer's Aunt Tina, the other aunt who had held him up in church, Edwina Doryen, died as well. Two weeks later, her husband, Mark Jerry, sat slumped outside an Ebola treatment center. Their daughter Princess sat to his right, resting her forehead against the wall. Both were too weak even to drink water.
For days, Mark had maintained his denials about the family illnesses. He was sick, too, but told friends he had typhoid and switched off his cellphone. After Princess fell ill, things changed.
"I'm convinced it was Ebola," Mark said.
It was mid-September, and Liberia stood on a precipice. Monrovia had become the focal point of the outbreak in West Africa. Infections were doubling every two to three weeks. Mark and Princess were lucky to receive treatment at all. But while Mark, 27, improved, Princess, 9, did not. She died within days.
After being discharged with a letter that he was "no longer infectious," Mark began work-ing for Doctors Without Borders. Once a denier of Ebola, he became an evangelist. Mark, a money changer, and Kaizer's Aunt Edwina, a restaurant worker, had spent years saving $900 to build their home, a simple structure steps away from the Doryen house. He had suspected that Kaizer had Ebola.
The unease felt by the Doryens' neighbors in Capitol Hill had unsettled him. But he had blocked out those doubts when Edwina got sick. What else could he do but take care of her?
"Edwina and I were like one person," he said. "I would bathe her. She was toileting all day. I would clean her, and then after two, three minutes, she would toilet. I would clean her again."
He took her to a local clinic, where they were told that she had a chest cold. Finally, with Edwina unable to walk and bleeding from the mouth, Mark carried her on his back and put her in a taxi to the hospital. Turned away for lack of beds, she was taken to an Ebola holding center. She died there the next day, on a brown mattress on a filthy floor, surrounded by body fluids.
A rage built within him. All the suffering -- all the pointless deaths in the family -- stemmed from a betrayal, he said: Mamie's refusal to admit what was wrong with Kaiser. She had at least suspected the truth, Mark said. Once Edwina became symptomatic, Kaizer's mother, the progenitor of the poisoning narrative, offered a suspicious warning.
"She said, 'Mark, the way you're taking care of Edwina, you got to get chlorine water on the side, and when you finish taking care of her, you wash your hands,' " he recalled.
"She acted very bad, my sister-in-law; she knew that her son had the virus and she never educated us," Mark said. "To me, she was wicked. I don't call that ignorance. I call that wicked-ness."
The disappearance of Kaizer's mother quickly set the Doryens adrift, leaving them to en-dure one loss after another without their central figure. Four of Kaizer's aunts and cousins died in
a month. Kaizer's grandmother died, too, on Aug. 31. But the Doryens did not even find out about her death for nearly two weeks. Mamie, as the head of the family, gave her cellphone as a contact number when the ambulance took away the grandmother. When Mamie disappeared, health officials were unable to contact the Doryens.
Mamie's absence stirred fierce disagreement, another source of division in the family. Some saw it as proof of her deception. Others, like her brother, Anthony Doryen, imagined her grief.
"Everybody is angry with her," he said. But "she herself lose her mother, she lose her son, she lose two sisters."
As word of the family deaths in Capitol Hill spread to Mamie's neighbors near the swamp, they grew alarmed. Mr. Mombo, who buried Kaizer, reached Mamie by phone after many at-tempts.
"Why you running from place to place?" Mr. Mombo asked her. "But since then, her phone is switched off."
Mamie insisted in a brief phone interview that Kaizer was poisoned and died after the woman in black told him he was "finished."
"Everybody is carrying my name around," Mamie said. "I didn't do anything."
"Nobody should blame me," she added. "The devil is very busy. The Capitol Hill people saying I'm the one carrying Ebola there. All my family dying."
By late September, after the death of Kaizer and six of his close relatives, the sickness seemed at bay. Twenty-three days had passed since the last sick family member was taken out of Capitol Hill, two days beyond Ebola's maximum incubation period.
"It's good to stay alive," said Abraham Keita, Kaizer's uncle. He smiled, stretched and brought out a DVD, "Monrovia on Fire," a local martial arts film in which he had a supporting role. He hoped for a bigger part in a sequel. Mr. Keita, a furniture maker and taekwondo master, was planning for the future.
One of the Doryen brothers had returned to Capitol Hill, though he still kept his wife and children away. Mr. Keita hoped the other Doryens would follow, including Mamie.
"Before, yes, I was angry," he said. "Everybody was angry with her." He laughed. "Now I can forgive her. That's what God says."
"Maybe after one month, two months, she will come back, because we are the same fami-ly."
In Liberia, too, the mood has begun to shift. New Ebola cases have dropped significantly, leading some international and local health officials to say they are making headway against the disease. On Thursday, President Ellen Johnson Sirleaf lifted the state of emergency imposed on the country, saying "we can all be proud of the progress."
Weeks earlier, Martha Doryen, Kaizer's aunt, stood outside her house. A cellphone num-ber and "Yah" -- Mamie's real name -- were scribbled on the front wall with charcoal. Mamie's new cellphone number?
Instead, Martha looked at her 13-year-old daughter, who had just celebrated receiving her first cellphone by writing the number on the house. Her name is also Yah. Thirteen years ago, Martha asked her big sister, Mamie, to name her firstborn. Mamie named the girl after herself, Yah, a new generation's hour come round at last.
Then, almost as an afterthought, Martha mentioned that Mamie had called that morning, the first time since she was forced from Capitol Hill a month earlier. Martha was sitting on her porch making dry rice with fish. An unknown number had flashed on her cellphone.
"She says she's fine," Martha said. "She's just telling us to wash our hands, stay away from people and be with ourselves. Because herself, she is O.K., taking the same advice she gave us."
Saturday, the 21st of September, is a day I will never forget in my life. I was out working with MSF as a health promotion officer in Foya, in the north of Liberia, visiting villages and tell-ing people about Ebola: how to protect themselves and their families, what to do if they start to develop symptoms and making sure everyone has the MSF hotline number to call. Later that
night, my brother called me.
"Your wife has died." I said, "What?"
He said, "Bendu is dead." I dropped the phone. I threw it away and it broke apart. We were together for 23 years.
She understood me. She was the only one who understood me very well. I felt like I'd lost my whole memory. My eyes were open, but I didn't know what I was looking at. I had no vision.
I had tried to talk to my family about the virus and to educate them, but my wife did not believe in it. I called my wife begging her to leave Monrovia and bring the children north so we could be together here. She did not listen. She denied Ebola. She was staying in the capital, Mon-rovia, with three of our children.
Later that same week, I received another call from Monrovia. My brother, who was work-ing as a nurse, had been taking care of my wife. But he became infected and died, too. Then my two youngest children were taken to the center in Monrovia, but my girls were very sick and they died. I felt even more helpless. I was breaking in my mind. I couldn't make sense of anything.
My eldest son, Kollie James, was still in Monrovia in the house where our family had been sick, though he was showing no signs of illness. He called me and said, "Everyone got sick, I don't know what to do." I told him to come here to Foya to be with me.
When my son arrived, people in the village would not accept us. They told us that our family had all died and to take Kollie James away. I was angered by their reaction. I knew he wasn't showing any symptoms and was not a threat to them, but because of the stigma, they wouldn't let us stay. We had to move on.
The next morning, though, I noticed my son looking more tired than usual. I was worried about him. He didn't have any symptoms like vomiting or diarrhea, but he just looked tired. I called the Ebola hotline and MSF brought him to their Ebola care center here in Foya to be test-ed.
When the test came back positive, it was a night of agony for me. I didn't even shut my eyes for one second. I spent the whole night just crying and thinking about what would happen now to my son.
The next day the counselors at MSF calmed me down. They told me to wait. To hold my peace. I sat with them, and we talked and talked. I was able to see Kollie in the care center from across the fence, so I called out to him, "Son, you're the only hope I got. You have to take cour-age. Any medicine they give to you, you have to take it."
He told me, "Papa, I understand. I will do it. Stop crying, Papa, I will not die, I will sur-vive Ebola. My sisters are gone, but I am going to survive and I will make you proud."
Every day, the counselors made sure they saw me, and they sat with me so I could talk. The way the counselors talked to me helped me relax. They knew it's not a small blow that I am receiving in life. I didn't want to see my son in there. When I saw him in there, I thought about his mother. I already lost her, I wanted him to survive. I wanted him to be strong.
After some time, my son started doing much better. He was moving around. I prayed that he would be free of Ebola and test negative, but I was worried that his eyes were still red. I just wanted us to be together again. Then something amazing happened, something I could not actu-ally believe until I saw it.
Until that moment I saw him coming outside, I could not truly believe that it would hap-pen. I've seen people with Ebola start to look strong and then the next day, they're just gone. So I was also thinking, maybe Kollie will be one of those who will be gone the next day.
When finally I saw him come out, I felt so very, very happy. I looked at him and he said to me, "Pa, I am well." I hugged him. Lots of people came to see him when he came outside. Eve-rybody was so happy to see him outside.
Then MSF told me that Kollie is the 1,000th survivor from Ebola. This is a great thing, but I was wondering, how many more people have we lost? How many have not survived? Of course I am so happy to have Kollie still, but it's hard not to think of all those who are no longer with us.
When I took him home with me, he actually had a smiling face. And me, too, I had a big
smile on my face. I had a very good smile that day. I decided to have a little party for him. Since then, he and I do everything together. We sleep together, we eat together and we have been con-versing a lot.
I asked him, "What's your ambition after you graduate from high school?" He's a 10th grade student. He told me that he wants to study biology and become a medi-
cal doctor. That's what he told me! So now I'm going to try every way I can to meet his needs and succeed in life, so that he should not feel so bad about the pain he has suffered losing his mother.
I told him, "Now I am your mother and your father. I am serving as both for you now." And he told me, "I will do everything for you as my father."
He is so pleased I called him to be with me. The care that was given to him here was a hundred percent. Now that my son is free of Ebola, we will make a life for ourselves. He is 18 now, so I will make him my friend. Not just my son, but my friend, because he's the only one I have to talk to. I cannot replace my wife, but I can make a new life with our son.
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AAbbdduull KKaabbiiaa FFrreeeettoowwnn
People from Liberia and Sierra Leone tell the BBC what it is like living in fear of Ebola. One of the most shocking, sad and sorrowful experiences of my life was the death of my auntie. She was the woman who brought me up. She felt unwell for a short while and then was diag-nosed with Ebola. A surveillance team came to confirm the death and told me that another team would come to take samples of her saliva and blood. When that team came, they were dressed in white medical overalls. They told us not to go near my auntie's body because the virus would still be very active.
Then another team came. The burial team came. We told them that we would not give them her body until they could prove she had died from Ebola. The burial team then called for police enforcement and the corpse was taken forcefully.
My auntie was put in the back of a van with six other corpses. We followed them to the cemetery where Ebola cases are sent to be buried but armed men did not allow us to enter be-cause of infection. They buried 17 corpses in a mass grave. This was the one of the saddest days of my life.
MM SSaahhrr NNoouuwwaann,, LLiibbeerriiaa
My brother--in--law's wife became very unwell and she had to go to the hospital. But she died in the car before she got there. All my family were very upset but also very afraid of con-tracting the virus. The symptoms started to develop in people that had been in contact with her -- about eight people developed signs and died.
My wife's brother did not contract Ebola, nor did my wife -- we were lucky. Many people who have Ebola are afraid to go to the hospital. I want to encourage people to get help. There are fewer clinics open and many deaths are due to the poor response of health officials. They need to increase the numbers of medics, social workers and facilities to fight this virus.
NNyyuummaa BBoonnddii,, MMoonnrroovviiaa
I know people who have died from this deadly Ebola virus. A doctor who had been help-ing sick people in my community -- even when public hospitals were closed -- contracted the vi-rus and died. A newspaper reporter has also died and one family lost three of its members. Since the outbreak, all hospitals have been closed throughout the country.
There are virtually no treatment centres. The ones that exist are filled to capacity and are no longer accepting new cases. Nurses and doctors have abandoned the hospitals because of fear of the virus. People have a sort of denial mentality -- most Liberians from remote and suburban areas of the country don't believe that the Ebola virus is real.
Some confirmed Ebola patients are escaping treatment centres. A lady who was diagnosed escaped the quarantine centre in Lofa where the outbreak started. Everyone who had been in di-rect contact with her became infected and only one doctor survived. So lying about infection is also responsible for the huge death rates in Liberia.
I wash my hands regularly with soap. I clean my clothes and I never shake hands with people. I try to protect myself and my family.
EEmmmmeetttt PP CChheeaa,, LLiibbeerriiaa
The Ebola outbreak has been like someone firing live bullets. Liberia is too poor to deal with this unaided. Thousands more will die if the international community does not come to our rescue.
The closing of hospitals and clinics in and around Monrovia has been one of the major factors increasing the deadly Ebola virus death rate because people who are coming down with the symptoms of malaria, high blood pressure, diabetes and diarrhoea are not able to get ade-quate treatment with the closure of health facilities.
The Ebola virus disease has upset my life. I'm a medical student and I should have sat my exams by now but the Liberian government closed all schools in August. We now live in fear and it is so intense that even having a small fever makes you very afraid. I tried to avoid mosqui-to bites as I don't want even getting the slightest illness. I have lost friends and colleagues. They should build a memorial to those who have died when this killer virus is eradicated.
A friend of mine died from Ebola. It is very frustrating -‐-‐ you never know when you are at risk even when we are all following the prevention guidelines. The health centres are too crowded. Relatives go there to see their loved ones die and they catch Ebola too. People are coming out of the isolation centres and are putting everyone at risk.
A friend of ours, Dr. Sam Brisbane, died recently. He was a Liberian doctor, and he died from Ebola, a horrible, nightmarish disease. Information coming out of Liberia has been scarce. Since Dr. Brisbane's death, we've learned that other doctors and nurses with whom we've worked have also contracted Ebola and have died or are being treated in the types of rudimentary facili-ties we see on the news. As we live in dread of each phone call, questions about how we die and what we're willing to die for have been weighing on us.
The ancients had a concept of a "good death" -- dying for one's country, for example, or gloriously on the battlefield. Solon, the sage of Athens, argued that one couldn't judge a person's happiness until one knew the manner of his death. The Greeks recognized that we're all destined to die and that the best we can hope for is a death that benefits our family or humanity. For emergency--medicine clinicians like us, the concept of a good death can seem too abstract, in-tangible.
Rarely are the deaths we see good or beneficial. We see young people who die in the throes of trauma; grandparents who die at the end of a long, debilitating illness;; people who kill themselves; people who die from their excesses, whether of alcohol, food, or smoking. Last year, as part of a new disaster--medicine fellowship program, we developed a partnership with John F. Kennedy Memorial Medical Center in Monrovia, the only academic referral hospital in Liberia.
We collaborated with the hospital administration to develop disaster--planning and resili-ence programs and teamed up with the emergency department staff to enhance medical training and establish epidemiologic studies of trauma. It was there that we met Dr. Brisbane, the ED di-rector. He immediately struck us as a genuine ED doc -- at once caring and profane, light--hearted one minute, intense the next. A short, bald man with weathered skin and thick glasses, he spoke openly and easily; his laugh was best described as a giggle, and he swore frequently.
When we conducted an initial vulnerability analysis for the hospital, we discussed our concerns about severe supply and personnel shortages, regular power outages, and occasional electrical fires. Dr. Brisbane replied that what scared him the most was the potential for an epi-demic of some viral hemorrhagic fever. He was right to be scared.
We encountered rationing of gloves, a limited supply of hand soap, and an institutional hesitance to practice universal precautions, probably because of the limited resources. The hospi-tal was not prepared for the kind of epidemic it's now facing -- nor was the city of about 1.5 mil-lion people.
During our time at JFK, we became friends with Dr. Brisbane. We learned that he'd trained in Germany in the 1970s, had returned to Liberia to work, and had chosen to stay through the civil war and during Charles Taylor's despotic rule, continuing to see patients despite the bloodshed around him. He had welcomed the country's new democratic leadership and a new female administrator at the hospital -- a first. He ran a successful coffee plantation and gave us bags of coffee every time we visited him. He was the father of eight biologic children and six adopted children, and he had numerous grandchildren around the world.
Within a few days after our return to Monrovia in June 2014, the city's first patients with Ebola presented at Redemption, the county hospital, and we soon got word that a doctor and some nurses there had died. Rumors were rampant, and staff quickly abandoned that hospital.
At JFK, our colleagues grew nervous. There were tensions between the hospital admin-istration and the public health ministry. There was no clear plan for what to do if a patient sus-pected of having Ebola showed up at the hospital. How would staff members protect themselves? How would they isolate the patient? How could they move the patient to one of the ministry's isolation centers? Dr. Brisbane was a wreck. He chattered nervously, his smile disappeared when he thought we weren't watching, and he openly wondered how he could protect himself. He told us bluntly, "Leave Monrovia."
Then one morning, we arrived at the hospital at 7 o'clock and ran into Dr. Philip Zokonis Ireland, one of our young doctor friends. He was agitated, his fear evident in his face: there was a patient in the ED with suspected Ebola. The patient had lain in a bed in one of the small, crowd-ed treatment areas for 6 hours, surrounded by nurses and other patients, until someone recog-nized his symptoms. We rushed to the room and met Dr. Brisbane and Dr. Abraham Borbor, the head of internal medicine.
Others were sensing that something was wrong. Patients and their family members quick-ly disappeared, and nurses hung far back in the hallway. The first priority was to get the patient out of the common room and into an isolation room, but the bed he was lying on was too wide for the doorway. So Dr. Brisbane, Dr. Borbor, and two custodians hastily donned gowns, gloves, and masks, then lifted the patient -- mattress and all -- and carried him into the isolation room, nearly dropping him in the process. The man had begun gasping for breath, and despite their ef-forts, within 5 minutes he was dead.
Later that day, laboratory tests confirmed that he was indeed infected with Ebola virus. His body stayed in the now--otherwise--empty ED until it was retrieved hours later by the health ministry. We remained in Monrovia for the next week and helped however we could. Dr. Bris-bane brought his own thermometer and checked his temperature religiously, fearing the telltale sudden fever. He wore a fedora in the hospital as a protective talisman. And yet he still joked with us, displaying a sort of gallows humor.
A few days after we'd returned to the States, we got a call from a friend in Monrovia say-ing that Dr. Brisbane was in isolation and had tested positive for Ebola. The next call informed us of his death and hasty burial on his plantation. By late August, Dr. Ireland and one of the nurses we knew had contracted Ebola and were fighting for survival, and Dr. Borbor and a phy-sician assistant who'd worked in the ED had died from the virus.
Dr. Brisbane didn't have to stay at JFK and continue to care for patients. He could easily have retired to his coffee plantation with his wife and children and grandchildren. He was terri-fied of Ebola, and yet we knew that every morning when we entered the ED, we'd find him there, seeing his patients.
Doctors and nurses have a duty of care toward their patients. We're expected, on the basis of our training and an unwritten social contract, to fulfill that duty even in less--than--ideal cir-cumstances -- in the face of depleted resources, for example, or undesirable patients.
But we also have a duty to ourselves and our families, and when our work becomes life--threatening, we have to decide what benefit we will be to our patients and what cost it will exact from us. In such circumstances, we cannot be expected to uphold the same duty of care. But dur-ing the world's worst Ebola outbreak to date, clinicians like Dr. Brisbane are on the front lines -- and are dying as a result. They care for patients despite the risks to themselves, despite the inad-equate supplies and infrastructure, despite their insufficient training in infection control.
Dr. Sam Brisbane's death diminishes us as a people. But with apologies to his wife and family, who saw him die horribly and unjustly, and despite the deep loss we feel, we believe our friend died a good death -- as did all the nurses and doctors who have sacrificed themselves car-ing for patients with this awful disease.
ATTACKS ON HEALTH WORKERS
AAUUGGUUSSTT
In August 2014 there were riots in Nzérékoré when a team tried to disinfect a market. Nzérékoré is about 30 miles (50 kilometers) from Womey.
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In September 2014 a Red Cross Team in Guinea was attacked while trying to collect corpses. Another medical charity had already pulled out of Guinea after multiple stoning attacks on their teams.
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Distressingly, a number of incidents have occurred during the fight against Ebola, in which frightened and angry people have attacked health workers and even accused them of bringing in disease.
"Early on in the outbreak, we had at least 26 villages or little towns that would not coop-erate with responders in terms of letting people into the village, even," said Gregory Hartl, a spokesman for the World Health Organization.
By 24 September 2014, Ebola disease was reported to have killed over 600 people in Guinea during previous months. The Massacre at Womey was the murder of 8 members of a team at the Womey village in the West African country of Guinea in September 2014. The team came from the Guinea government to inform the village about dangers of the Ebola virus disease.
On 18 September, it was reported that the bodies of a team of Guinean health and gov-ernment officials, accompanied by journalists, who had been distributing Ebola information and doing disinfection work, were found in a latrine in the town of Womey near Nzérékoré.
The workers had been murdered by residents of the village after they initially went miss-ing after a riot against the presence of the health education team. Government officials said "the bodies showed signs of being attacked with machetes and clubs" and "three of them had their throats slit."
When the group first arrived at the village, people threw stones at them, causing the group to split up with 9 trying to hide near the town of Womey, and others taking refuge near Nzérékoré and survived. The other 8 members of the group were killed at the village. The survi-vor, a journalist, said that they heard the villagers searching around for them.
The team included at least two doctors, including the Health Director of the prefecture and the Deputy Director of the hospital in the area. The Pastor worked at a local Christian church and was one of the founders of Hope Clinic, which provides medical care and surgeries. Some of the journalists worked for Liberate Zaly Fm. It is a local radio station based in Nzérékoré. .
The bodies were found in a latrine with evidence of being struck with clubs and machetes, and three were found with their throats slit. As the evidence was found, six were arrested in con-nection with the attack. By 22 September 2014 twenty people were arrested, and by 24 Septem-ber 2014 Guinea police had arrested 27 suspects in connection with the attack.
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A Red Cross team was attacked while collecting bodies thought to have been infected with Ebola in Guinea on Tuesday. One Red Cross worker is still recovering after suffering a wound to the neck in Tuesday's attack in the southeastern town of Forecariah, according to Be-noit Carpentier, a spokesman for the International Federation of Red Cross and Red Crescent Societies. Resident Mariam Barry told reporters that family members of dead Ebola victims had set upon the six volunteers and vandalised their cars.
A crowd eventually gathered at the regional health office, where they pelted the building with rocks. The incident comes after a string of attacks on teams attempting to safely bury dead bodies, as corpses not dealt with correctly spread the deadly disease. The officials also aim to provide information about Ebola and disinfect public places.
Last week, eight health workers educating people about the virus and journalists accom-panying them were abducted and killed in Guinea were abducted and killed. And in April, Doc-
tors Without Borders briefly pulled out its team from the Guinean town of Macenta after their clinic was stoned. In Liberia, the homes of some of the infected have been attacked.
Last week, Red Cross workers were threatened in Sierra Leone, Carpentier, the Red Cross spokesman, said. As the disease is new to this part of the world and so relentlessly lethal, people fear outsiders are associated with Ebola, even if they are coming to help, said Meredith Stakem, a health and nutrition adviser for Catholic Relief Services.
She added that people in the affected communities may not be familiar with basic biologi-cal concepts of disease transmission, and the spread of Ebola contradicts what they do know. "There's not a lot of diseases that can be transmitted by corpses," she said. "It's hard for people to comprehend that the dead body is actually a threat."
Ebola is thought to have infected more than 5,800 people across Liberia, Sierra Leone, Guinea, Nigeria and Senegal. The outbreak is the largest the world has ever seen, partially be-cause it went undetected for months, began in a highly mobile area and spread to densely popu-lated West African cities.
They were sent in to help educate villagers about how to ward off the lethal virus. Then fear took over and the machetes came out. At the time of Wednesday's announcement out of Guinea that seven of nine missing Ebola workers had been found dead, we knew little. Men with knives had abducted members of a group sent there to spread awareness about the disease. Two relief workers were missing; the rest, dead. Six suspects were in custody.
By Friday morning, we knew more. These details, the stuff of horror films. A local gov-ernment group of relief workers -- a mix of doctors, religious leaders, and journalists -- had ar-rived Monday to educate the remote southeastern village of Womey about Ebola. Just 24 hours after their arrival, violence broke out, allegedly sparked by the false belief that a disinfectant be-ing sprayed was actually the disease itself. An angry mob brandishing machetes, stones, and knives lashed out.
Some of the relief workers were lucky enough to escape to nearby villages. At least nine were not. Three had their throats slashed. By then, villagers themselves began to flee. Those still in Womey cut down trees and fashioned makeshift blockades so no one else could get inside the village. Two days later, when authorities did, they found eight bodies in the latrine system of the local school. Among the dead, three local radio journalists, two medical officers.
It's difficult to refrain from instantly demonizing the perpetrators, or focus on anything other than their crime. In a story so horrific, the grisliest details win the audience. The killers murdered, in cold blood, the very people that came to save them. It's easy to call such actions evil -- but entirely irresponsible to declare, with absolute certainty, that they were driven by any-thing less than unimaginable fear.
In an environment of uncertainty, fixating on the accused is comforting. Men can be cap-tured, arrested, imprisoned. They're a conquerable enemy. But that narrative, the one of sense-less, blood-hungry murderers roaming the villages of West Africa serves no one. The truth is likely more nuanced and, as such, more terrifying.
The truth is that a horrific, incurable virus is ravaging Guinea -- and at least three other countries in West Africa. That there is a rapidly shrinking number of doctors left to treat the thousands who are already sick and the millions that could be next. That the vast majority of those who enter hospitals, never come out. That, in the absence of an explanation as to why, par-anoia takes over. That a few white and Western-trained doctors have intentionally used disease to harm Africans in the past. That this unfortunate truth makes the heroic ones fighting coura-geously there now, the object of a very real fear.
We know little about the identity of the six suspects, but a lot about the country in which they live. With an estimated population of 11 million, Guinea has one of the lowest literacy rates in the world. More than half of the population lives below the poverty line, and 20 percent in ex-treme poverty..
UNICEF estimates that less than 50 percent have access to clean drinking water. In 2013, the International Monetary Fund measured Guinea's gross domestic product per capita at just $564 (in the U.S. the same year it was $53K).
Since March, a country already struggling to meet the basic needs of its citizens has been battling a lethal disease they have never seen. Without a cure for the virus, more than half of
those infected die within days of contracting it. With the rate of physicians per 1,000 citizens at less than 1 percent, there aren't enough doctors in the whole country to explain why.
According to the World Health Organization's most recent report, there have already been over 950 confirmed cases of Ebola in Guinea -- a set of numbers which the director of the organ-ization called a "vast underestimate" of the reality. Over 600 of those cases have resulted in death.
Out of the small number of health care workers in the nation, 60 have already been in-fected. Thirty-one have died. By the time the Ebola workers arrived to Womey -- on a vital mis-sion that may have very well helped it -- the village was likely overcome by fear and panic. Two months earlier in Kolo Bengou, a remote part of Guinea 400 miles from the capital, terrified vil-lagers attacked ambulances and dismantled bridges to keep doctors out.
In Guéckédou the same month, reported The New York Times, a local leader perpetuated the mistrust, telling his people: "There is no root, no leaf, no animal that can cure you. Don't be fooled."
Uninvited strangers in hazmat suits could alarm even the stablest of communities. But in a village crippled by poverty, tyrannized by war, and now suddenly overcome with a strange new illness, it is likely scarier than the wildest of nightmares. The men who killed these courageous workers committed a heinous crime. Perhaps they were simply depraved.
Perhaps, instead, they had reached a desperation we can't quite fathom. Perhaps they were merely trying to protect their families, their friends, their community and truly believed that this was the only way. Condemning them obscures the larger message to be taken from this atrocious crime. It is Ebola that is still winning. Ebola, not those who it has driven to commit evil acts, that is the true enemy.
Terry O'Sullivan spent three years working in public health in neighboring Sierra Leone and saw the need for treating powerless, poor communities with sensitivity. "This tragic event highlights both the tremendous power of rumors and fear of the unknown," he said, now as the director of the Center for Emergency Management and Homeland Security Policy Research at the University of Akron.
"That applies to both local politicians--who, in countries like Sierra Leone, often treat poor rural villagers callously -- as well as outsiders coming in with assurances that what they know what's best."
It's a lesson that's been learned much closer to home, too, O'Sullivan said. "As Americans found out during the early years of the HIV AIDS crisis, fear of a deadly unknown disease can cause people to react negatively--even violently ...
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Guinean government spokesman Damantang Albert Camara has reported officially that the bodies of eight people, including Rev. Moise Mamy and others from an Ebola education del-egation, were found in the village of Womey in southern Guinea. Government officials were among those who died, as well as three news reporters. Six arrests have been made.
Moise was a member of the Eau de Vie Ebola awareness team, a ministry of CAMA. "Many places accepted their teaching," wrote Jon Erickson, an Alliance international worker and colleague of Moise's, "but some villagers had heard a rumor that the bleach they were distrib-uting, which kills the Ebola virus, was actually the virus itself."
The BBC reports that the bodies were recovered from a septic tank at the local primary school. The Alliance waited to report the deaths until the identification of Moise was confirmed and the family members were notified.
In addition to being executive secretary of Eau de Vie and cofounder of Hope Clinic, Moise was an evangelist and the superintendent of the Alliance church of the Mano, his people group.
Please continue to pray for the families of those who died, particularly for Moise's wife, Nowei, and their five adult children, one of whom is a student at West Africa Alliance Seminary (FATEAC) in Cote d'Ivoire. Pray also for the Hope Clinic staff, who are devastated by the loss, especially Jon and Anja Erickson; Moise and Jon were like brothers to one another.
In 2008, Moise wrote his life story for Alliance Life magazine. Read his powerful testi-mony of God's redeeming grace.
I come from a pagan family, so I grew up worshiping the "grisgris" [magic spells] and our ancestors' tombs. In 1968, when I was 10 years old, my parents enrolled me in the school in N'Zao, Guinea. I pursued my studies until 1974, reaching the seventh grade. I was my grand-mother's favorite grandson, and since the teacher was strict, my grandmother advised me to quit.
At that time, I thought about getting married. So, without telling my family, I got engaged. Some time later, my uncle entrusted me to a truck driver to learn how to drive. While I was learning my fiancée, Nowei Male, was injured and was hospitalized for two months. When I re-alized that by being a driver, I couldn't see her anymore, I decided to become a mechanic.
When Nowei healed, her parents asked her to live with her older sister in Liberia. A week after she left, I told my uncle that I wanted to continue my apprenticeship in Liberia. He entrust-ed me to his brother-in-law in Monrovia. After 18 months, I signed a four-year contract, and Nowei and I got married. During the first year, we had a daughter, who died three days later.
I was paid $75 every two weeks. When I got my salary, I would buy one bag of rice and give $14 to my wife. Then I would take the rest of the money and live with other women. Often, I stayed away from home several nights in a row.
In 1977, we had our second child. Since Nowei was nursing him, I would drop by during the day but spend the night elsewhere. When she asked about it, I would answer, "You are nurs-ing, and you are not supposed to know where I am sleeping."
In our custom, a nursing woman is not allowed to sleep with her husband, because it is be-lieved that if she has sexual intercourse, the child will die. I used this to justify my relationships with more than five other women.
When Nowei told me this was not how married life should be, I answered, "You shouldn't tell me that! You have a bag of rice and the price of sauce on top of it."
"Take your rice and your money," she said. "I did not get married for these things--it is you I want."
I did not care about her advice, and I continued my wanderings. Sometimes I even brought women home and slept with them in the same room as my wife. She was forced to accept it be-cause I was very strict with her.
When the four-year contract was over, I stayed in Monrovia to look for work and sent Nowei back to N'Zao. Alone, I had even more freedom. I started going to different churches just to find girls. When the pastor was preaching the Word of God, I listened but did not understand. Yet God was looking for me, and a voice started speaking to my heart, "Moise, Moise, I need your life."
I moved to another city to find peace, but it was impossible. One day, a friend gave me an English pocket Bible. Little by little, even though I did not understand what I was reading, my heart was warmed. I could still hear a voice saying, "I need your life." I thought about going to a church but did not know which one. Then this voice inside said, "Go back to your family."
When I arrived in N'Zao, I was happy, but the peace still wasn't there. I lit two candles and told my wife, "Come, let us pray." Nowei laughed and asked me if this is what I was doing while we were apart. I told her, "No, but there is something that speaks into my heart and tells me to pray. I have seen people do this in churches, so come. We will do the same."
That is how we started. Nowei would sit next to me, and I would read the Bible. I did not understand anything and did not know how to pray either. One day I said, "Come, let us enroll in a Catholic church." She accepted, but I did not have time that day.
Soon after that, a relative died. On my way to visit the family, I met a man by the side of the road. As he shook my hand, I heard a clear word in my heart saying, "Ask this man what he does." He told me he was an evangelist and asked me if I was a believer.
I told him no and asked him how much I should pay to become a Christian. He told me it would cost a lot, but it wouldn't be money I would have to give -- it would be my whole life. Then he told me that God loves me. This was the first time I had heard someone say that.
I spoke with him for a long time, and he asked me if I was ready to give my life to Jesus. Since I had promised Nowei to enroll in a church, which for me would mean becoming a Chris-tian, I told him to come to my home so we could discuss it with her. A few days later, he came with another evangelist, and I was very happy to welcome them.
That evening, he started singing in the village, and many people came to listen. When he finished preaching, no one accepted his invitation to follow Jesus. Afterward, he asked me why I did not go forward. I did not tell him I was ashamed, so I said, "You came for me, so let us go home." Nowei and I became Christians that day, August 11, 1984, at 11:30 p.m. I received a New Testament in Mano (my mother tongue). For the first time I had a book that spoke about my life.
First Peter 5:8 says, "Be self-controlled and alert. Your enemy the devil prowls around like a roaring lion looking for someone to devour." After I had been a Christian a year and a half, my relatives decided to send my sisters into the sacred forest for initiation into adulthood. I told them my wife and I would not take part because we had become Christians and the Bible tells us not to do this.
They did not understand what I was talking about, so the initiation began. Since we were not participating, the devil used my family to tempt us. My sisters spent two months in the forest, and every day someone needed to bring them firewood and meat. But we refused. This was the beginning of great discord with my family. The day my sisters came out of the forest, Nowei and I did not join the family but worked the fields. Then the devil changed his tactic and sent illness.
Early one morning I begin having extreme stomach pain and could not get up. For one hour, I was in agony while my wife sent word to my father. He came with a piece of kaolin [a clay mineral] in his pocket. He told me, "It is your ancestors who have taken your stomach. You need to eat the kaolin to take the pain away."
I told him, "God lives in me, and the ancestors have no more power over me."
My father said that I was denying the truth. He and some boys carried me to the village in a wheelbarrow. There, everybody came to look at me as if I were a criminal. My mother started to cry, saying that I had disobeyed their god, who was taking me back.
My family members told me they would do everything so I could be freed. I answered, "Let me die. I will go to my God, but I will never ask forgiveness from the ancestors. I am now following GOD." Everybody started to cry.
I told Nowei to ask Nicodeme, a Christian villager, to come pray for me. After he prayed, I asked my wife to find a nurse to give me some medication. The treatment worked, and God saved me from the illness. Today, I praise the Lord because my father and mother have become Christians.
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Church leaders in West Africa are raising concerns over sporadic violence that has killed one of their own and frustrated efforts to stem the Ebola epidemic. The violence took a danger-ous turn last week in a remote village in southeast Guinea, when fearful villagers killed eight members of a disinfection and awareness team, including an evangelical church pastor.
The Rev. Moise Mamy, was a member of the Water of Life Ebola awareness team, a relief wing of the Christian and Missionary Alliance. He headed the Hope Clinic, a facility providing medical and surgical services in the remote village of Womey.
The villagers used machetes and rocks to kill the eight and later dumped their bodies in a septic tank at a local primary school, according to news reports. The murders have sparked out-rage within the aid and church communities in West Africa, where superstition and myths pre-vail.
"The people were on a humanitarian mission," said the Rev. Tolbert Thomas Jallah Jr., general secretary of the Fellowship of Christian Councils and Churches in West Africa. "They were trying to assist under a very difficult situation. Their killings and the violence are totally unacceptable."
In Womey and its surroundings, some people refuse to acknowledge the existence of Ebo-la and accuse the health officials of intentionally infecting the populations. Information on Ebola eradication efforts are viewed suspiciously as Western propaganda and distribution of chlorine-based products are rejected as attempts to destroy villages.
This mistrust exists beyond Guinea, church officials say, and has resulted in periodic vio-lence and protests in areas where governments have attempted to isolate those infected by the virus.
The World Health Organization said Thursday (Sept. 18) many of the estimated 700 new
infections are in Liberia, but the situation remains dire in Sierra Leone and Guinea. Nigeria, Sen-egal and Democratic Republic of Congo have recorded some cases.
Jallah said the epidemic was destroying economies, disrupting markets and farming. He warned it was a matter of time before serious food shortages hit the region.
"This really is a difficult situation," he said.
Recently, several airlines stopped flying to the West African countries raising concerns among relief organizations and churches that medical supplies and equipment will not reach those affected.
"We passionately plead with airlines to resume flights to our affected countries to help us fight Ebola," said Ebun James-Dekam, general secretary of the Council of Churches in Sierra Leone.
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UNICEF states the by October, at least 3,700 children in Guinea, Liberia, and Sierra Leo-ne have lost one or both parents to Ebola since the outbreak's start.
Once the little boy was taken to the survivor's home, the community around refused to let the boy stay with her because of the fear, because of the stigma, that the virus could come into the community.
" The figures are climbing," says Andrew Brooks, UNICEF's head of child protection for West and Central Africa. In Liberia alone, where he's currently based, Ebola has robbed about 2,000 children of their parents. One particular case struck him.
On Sunday, he says, "I was called to one of the Ebola treatment units urgently. There was a 4-year-old boy there whose mother was admitted a couple of days before. She had arrived in such a terrible state that the social workers could get very little information from her. All they had was the mother's name, two cell phone numbers, and the boy's name -- not even his age."
The woman died. Her son was tested for Ebola, and the test result was negative.
"So, there was a need to get the boy quickly out of the Ebola treatment unit," Brooks says. Treatment centers are rough places for children, and also are filled with the potential for infec-tion. Government social workers found a survivor, considered likely immune to the disease, who was willing to take the boy in that day.
"But once the little boy was taken to the survivor's home," Brooks says, "the community around refused to let the boy stay with her because of the fear, because of the stigma, that the virus could come into the community."
The boy was moved to the home of another survivor. A social worker was able to track down the boy's aunt, who was overjoyed to learn that her nephew was still alive. He'll move in with her once he clears the 21-day incubation period. "There are many more like him," says Brooks. "His case shows the complexities of managing this kind of care for a child."
This isn't the first time Brooks has worked with stigmatized children. Years ago, he worked in Liberia with Save The Children to resettle former child soldiers, sometimes back into the very communities where they had committed atrocities. Those were not easy negotiations. "But this is another dimension," says Brooks. "These children ... do represent a real risk, a con-tinued risk, when they start showing symptoms."
To some extent, the fear of these orphans is legitimate, he says. They've been in close contact with infected people. Even if they test negative for the disease early on, they aren't con-sidered fully clear until they've made it 21 days without showing any symptoms.
Still, even people harboring the virus aren't contagious unless and until they show symp-toms. Brooks says the focus now should be educating caregivers about how to care for a poten-tial patient safely -- and to seek medical care quickly if the child develops early signs of infec-tion.
"As much as possible, children should be cared for by the normal people who care for children – their families, extended families, communities," Brooks says. The Liberian govern-ment is strengthening the systems that allow social workers to track down extended family mem-bers, he says.
"As a last resort, we're starting to work with the government to put in place some centers -- called interim care centers -- where children can go for the 21-day period," Brooks says. The
centers are meant to provide "the reassurance and the confidence that the communities and fami-lies would need to be able to take the children home," he explains. "But it's an uphill struggle, and the needs are far surpassing the available resources at the moment."
In 30 years of practicing medicine, Dr. George Risi has never had an experience as emo-tionally draining as his month in Sierra Leone. Risi, 60, is an infectious disease specialist. His life in the mountains of western Montana, with his wife and high-school age son, is very com-fortable. He enjoys skiing, hiking and fishing.
But he left that behind for a month this summer to volunteer at one of the busiest Ebola hospitals in Sierra Leone -- Kenema General Hospital, the country's largest Ebola treatment cen-ter. Risi had never actually seen a case of Ebola until he went to Sierra Leone. He estimates he treated more than 300 people. About 100 died.
"I've never seen that much concentrated death at any one time," he says. "You'd developed a relationship with these people. You knew them, and to walk in and see a previously healthy, vibrant person, sometimes in their 20s, or sometimes small children, and to find them dead the next morning, that was very, very difficult."
Risi says it was also difficult working 12 hour shifts in the hot, bulky protective gear that health workers wear to avoid becoming infected.
"There were times when you were exposed to a lot of blood, or a lot of diarrhea fluid. And if that were to happen, then you needed to walk away right away," he explains. "There was a chemical sprayer inside the ward so you could spray yourself right then, at that moment."
Risi tried hard to buoy the spirits of the local nurses he worked with. There were no local doctors at the hospital; all had died from Ebola. Some Ebola survivors stepped in to help.
"There was one, who came in with her husband. Her husband died, but this woman, her name was Martha, and she not only survived, but she improved to the point that she was able to care for a lot of the small children," he says.
"There are many kids who have been orphaned, but there was nobody to care for them. And so Martha in particular took on the task of feeding and bathing and just taking care of a half a dozen kids, and that was quite a remarkable thing."
Risi will also remember how grateful people in Sierra Leone were for outside help. "I can't tell you how many times people just expressed their gratitude. They would see us even in the street, because it was pretty obvious we weren't locals, and people would stop us and they would just say, 'Thank you very much for being here.'"
LLOORREENNZZOO DDOORRRR OOCCTT 88
"Now we're in it." That's what Liberian health worker Lorenzo Dorr tells me. The first two cases of Ebola
have been confirmed in Grand Gedeh County, in Liberia's southeast, where Dorr is based. Dorr first spoke with Goats and Soda a few weeks ago about his work with Last Mile Health, a non-profit in Liberia that trains and deploys health workers in remote communities. Throughout Sep-tember, he's continued coordinating anti-Ebola activities and training and equipping village health workers in the southeast of the country.
He spent time in Rivercess County, one of Liberia's poorest, to begin addressing that un-derserved area's critical health needs. When the 50-year-old father of four returned home to Grand Gedeh, he helped welcome Dr. Paul Farmer and colleagues, who'd traveled from the Unit-ed States to start setting up a new and much-needed Ebola treatment center in the county's main city, Zwedru.
Until last month, Grand Gedeh had been one of the lucky few Liberian counties to remain free of Ebola. Now that it's not, Dorr's efforts have become all the more important. The first case in Grand Gedeh Country came in late September.
What was the reaction? Everybody in town was shocked. Every time there has been a meeting and they have said Grand Gedeh is Ebola-free, people clapped their hands, and there was applause. This time people became very disappointed. I think they are very, very much dis-appointed. However, everyone will be doing all he or she can to ensure this will be the only case in Grand Gedeh.
The good news is that the patient became a survivor. So Grand Gedeh can now boast of a survivor. His family members will have to go 21 days in isolation. But this week, another case has been confirmed, and the patient died. It is more imperative now than ever before to try to strengthen awareness strategies and case identification.
On the local radio at 8 a.m., after the first case of Ebola became public, the county super-intendent was very angry and gave a strong warning. The confirmed Ebola case was visiting from elsewhere in the confines of the Zwedru Central market and was not reported by the mar-keters. The marketers kept silent, they didn't report it to the county health team. If it happens again in the future, he will close the market down until the Ebola epidemic is over in the country.
It will be taken seriously. People should report strangers. This is not the time for people to go from one community to another. They definitely will not be welcome.
Even if community health volunteers are trained, since 2012 they have not received drugs. The NGO that supplied drugs closed and left. The storeroom is almost empty. The clinics in the county were each given five sets of personal protective equipment. One of the clinics has already used three, only two are left.
There are also no pediatric drugs in the clinic I visited for HIV/AIDS clients. We toured the hospital. It's so limited you'd think it was not a hospital. The hospital does not have bedding, there are very tight rooms, and they need expansion. These are very deplorable conditions; there is not even oxygen in the delivery room. The medical director was saying the operating theater is so hot, there is no air conditioning.
The hospital lacks gloves. The certified midwives recycle gloves in the delivery room, they reuse them. There is no linen, most of the beds are without water-resistant covers and are easily soiled. In some cases, there are mattresses made of mackintosh [raincoats] -- so they will not be soiled. The hospital needs to have bedding.
They can't just put a patient in a bed like that. You have to keep the integrity of the pa-tient. Another major challenge is lack of training. There are two confirmed Ebola cases reported in Rivercess. They are doing all they can. They're looking to us as a key partner in this fight and beyond.
The long-awaited training covered county officials and other stakeholders as well as health workers in the hospital, health centers and public and private clinics in the county. Train-ing is one thing and availability of equipment is another. It is still not quite clear how much per-sonal protective equipment has been provided and is available. Without these, the training is not useful.
This is the last month of the rainy season. The roads are continually bad. It's affecting eve-rybody. Two of our staff left early one morning for Monrovia but could not make it through. It took me two days to reach Monrovia over this past weekend. We slept in our vehicle.
It takes days to transport blood samples and specimens of suspected, probable and alert cases to the testing center at Liberia Institute of Bio-medical Research in Margibi County. And it takes 72 hours for a blood specimen to remain viable for testing, and so the sample needs to ar-rive at the testing center before the 72 hours expire.
It's a very serious situation. You can't send it under the current conditions. The worsening road condition has also affected food supply to the counties in the southeast and availability on the markets in these areas, resulting to hacking of prices of basic goods. There are also severe drug shortages in the counties resulting from either lack of commodities at the National Drugs Service or bad road conditions that make road transport difficult.
The lack or acute shortage of essential drugs and supplies in the facilities is keeping away
sick people and rendering it rather difficult for health care workers to identify cases for early in-tervention, which is cardinal to increase the chance of surviving Ebola.
WWhhaatt ccaann bbee ddoonnee??
A lot of great and good works have been done and continue to be done in the fight against the Ebola in the country. However, I strongly feel that in order to succeed in this fight, we must be holistic in our approach. A friendly environment needs to be created to allow for the sharing of information. Food needs and other basic needs of vulnerable people must be met to ensure ad-herence to prevention and control measures.
Roads must be improved to allow free and easy movement of people, to prevent clustering and direct contacts in case of a vehicle stuck in the mud or deep potholes and to facilitate easy referral and transfer of cases from one point to the other. Drugs and medical supplies must be readily available at all times in health facilities providing care. And the availability of testing and treatment centers within easy reach cannot be overemphasized.
Dr. Farmer assured us they are standing with the citizens in the fight against Ebola. He is passionate about what the country is going through. We are very hopeful that it won't be long until he is back in the country to start work. The scope of intervention they have in mind is very important. Currently there is no treatment or testing center in the county. The Partners in Health testing and treatment center is very welcome. We look forward to working with such an organi-zation and seeing our dreams realized.
Given the experiences of the Liberian people in years of crisis, people will be a little bit apprehensive. What we learned so far is the military will establish Ebola treatment units in the country and mobile testing facilities. That is good news. Everybody is happy. But people are still speculating there might be another agenda other than establishing an Ebola treatment unit.
I'm not really worried. I think everybody knows what to do. But it sends out a very bad message. If the staff from the ministry is infected, it quite clearly demonstrates the weakness of the system. It will make people lose confidence in the system.
We know exactly what it means when we talk about war. In a war, one can identify one's enemies and know how to escape. One can leave and hide. But you cannot hide from this. And if you hide with people in the bushes, the people you are hiding with may be infected. In a war, you can embrace others; you can care for each other.
But this Ebola crisis is against intimate friendship and against love. In a war situation, car-ing for wounded family members is not limited by conditions such as is the case with Ebola. In wartime I have seen family members holding their wounded relatives in their arms, soaked in blood.
Even as a health care worker, I have been overwhelmed with patients, wounded from war, soaked in blood, which I must care for with little or no PPEs such as gloves and without so strong a fear of being infected as is the case with Ebola. For many people, this is more than just war.
I will tell you something. The funny part -- it is sad and funny -- is if you ask people now between HIV or Ebola, what do you prefer, many will say, "We prefer HIV," even though there is no cure. This is how serious things are.
There is a huge difference. The international humanitarian machine is cranking up. The hotel where I'm staying is packed with people from the U.N. and aid agencies. There's big vehi-cles moving people around, construction projects with USAID tarps covering them. There's very much this sense that the cry for the international community to pay attention has finally been an-swered.
There's a bit of a sense of Ebola is becoming the new normal. The streets are supercrowd-ed and busy. Despite government declarations that people aren't supposed to gather in large crowds [to prevent the spread of Ebola], the markets look like any street scene. Traffic was fairly light in August but it's once again terrible. There are traffic jams. It feels like, in many ways, life has gone back to normal. And yet it hasn't. On the radio everybody is still talking bout Ebola, and there are lots of Ebola songs, some old ones, some new ones, and signs everywhere about Ebola. All schools remain closed.
HHooww iiss iitt ffoorr yyoouu,, wwoorrkkiinngg aass aa jjoouurrnnaalliisstt??
The government put out a declaration this week requiring all reporters to get written con-sent from the ministry of health before they talk to any Ebola patients or enter any treatment fa-cility or talk to anyone outside any treatment facility.
Politically there's been this push by President Ellen Johnson Sirleaf to cut back the press coverage, forcing local journalists to register with the government in a very restrictive way. They have to provide details of who their landlord is, where their newspaper is printed. I think there's a little bit of a sense that the government is not happy with some of the press coverage and are try-ing to control it.
There's a growing frustration with the inability of the government to get this outbreak un-der control. And there was a lot of anger about the way the government responded to the Thomas Eric Duncan issue [the Liberian citizen diagnosed with Ebola in Dallas, who subsequently died].
People felt like the government, rather than standing up for him and trying to help him, at-tacked him. There were threats by the government to prosecute him if he returned home. Some people felt: The man's on his deathbed with this horrible disease and on top of it his government is blaming him for having brought Ebola into the U.S., when he might have had no idea he was infected.
This crisis is no longer just about a disease. It's so permeated Liberian society that politi-cians are bringing it up. The government's handling of it is definitely now a political issue.
We went to this amazing Ebola task force meeting in Bomi County, about a 90 minute drive north of Monrovia, the other day, and it just sort of summed up the scope of issues. Bomi has only had 116 cases of Ebola, which is not a whole lot. Yet Ebola has come to dominate eve-rything.
The burial plots are completely full now. The county has a new contract with this NGO to dispose of the bodies. All burials have to be done by this team. But the NGO doesn't believe it's their responsibility to actually dig the hole in the dirt for the grave. So it's unclear who's sup-posed to be digging. Then there was this guy who went to Monrovia and died. And they couldn't get a confirmation of whether he died of Ebola because nobody could find the blood sample.
Yes. And the chief medical officer says, 'Well, nobody else wants to admit it, but I know who his mistress was and I'm putting his mistress in quarantine." And there are other people the officer said should go into quarantine but were refusing to go into quarantine. Issues like that are starting to play out.
And they've broken ground on one of the 17 Ebola treatment units promised by the U.S. And they're gearing up to figure out how they're going to staff it. And people in the town don't want any Ebola survivors working there because of false rumors that survivors could be infec-tious.
It was one thing after another in this meeting. Managing Ebola effectively comes down to making sure all the details work right. And things have always been a bit chaotic in West Africa. The meeting underscored just how difficult it is to do everything that needs to be done to make sure this disease gets under control.
We're hearing now there are beds available. But yesterday I went to the house where Eric Duncan's landlord lives. And on the porch of the house where Duncan helped the pregnant wom-an who seems to be the source of transmission of Ebola to him, there's a guy laying out and he's completely sick. And there's a woman sitting on the porch in a chair. She's looking after him.
He likely has Ebola and he's lying on a porch? And who is the woman -- a government health worker?
No. She said, "I'm not from around here, I've come to look after him." She seemed like a friend of the family. So for whatever reason, people who have Ebola are not necessarily getting into the treatment centers. So things are back to normal and yet nothing is normal.
It is quite clear that this thing is not under control. The question is how you're going to get this cat back in the bag. Some reports show that the number of new cases is flattening out. Maybe they're leveling off, maybe even starting to go down. But numbers are still so large. There's a steady stream of vehicles pulling up to the zone where people get dropped off at an MSF clinic.
As soon as the Ebola outbreak started to spiral out of control in West Africa, Kwan Kew Lai felt obligated to help. She's a physician who specializes in infectious disease. And for the last decade, she's dedicated herself to volunteering for international health emergencies. She works part-time at one of Harvard's teaching hospital just to have that flexibility.
But finding an organization to deploy her has proved challenging and time-consuming. The group she normally goes out with pulled the one doctor they already had in Liberia and shut down further operations in early July -- after two American health workers from different organ-izations got infected. Lai's group decided they weren't equipped to treat Ebola patients. Lai didn't give up. She figured she'd just find another organization to work with. "I just said to myself, 'I can't be sitting here at home,'" she says. "'I really need to be there.'"
So she wrote the World Health Organization. She says she got one email requesting in-
formation she'd already given them -- then never heard back. She also tried USAID, the agency that's leading the U.S. government's response in West Africa. They've set up an Internet portal for medical workers who want to volunteer.
Medical professionals log in to the portal and enter their experience and contact infor-mation. "Then every day we share the contents of the portal with about 150 non-governmental organizations that are either working in West Africa or supporting health sector work in West Africa," says Juanita Rilling, director of USAID's Center for International Disaster Information.
So far about 2,700 would-be volunteers have signed up. But Lai found that aid groups have been slow to sift through the list. She put in her application in early September. But she's only now hearing back from many groups, including a number she'd already contacted directly in the meantime.
And Lai says she thinks a lot of other volunteer hopefuls have been similarly "flounder-ing," as she puts it. Lai, at least, has finally found a placement. Nearly three months after she started her search, the aid group International Medical Corps, or IMC, signed her on to help run an Ebola treatment unit in a rural county of Liberia. But here, Lai ran into another issue. Whereas she was ready to leave in as soon as two weeks, IMC told her it would be more like a month and a half.
While IMC ultimately plans to operate four Ebola treatment units, it would be dangerous to ramp up the effort too fast, says Rabih Torbay, the group's senior vice president for interna-tional operations. "We start small just to make sure that patients are coming and that we have all the protocols in place and the staff are comfortable," he says. "Then we increase the bed capaci-ty."
He adds: "We're not starting all four [treatment units] at the same time because that would be overwhelming."
Many would-be volunteers who have full-time jobs at hospitals are facing yet another ob-stacle: reluctance from their employers. This includes several dozen medical workers who've told the leadership at Mass General Hospital and an affiliated hospital in Boston that they want to go.
Mass General regards that kind of service as a core part of its mission. They often give in-centives for people to volunteer, including time off and some pay. But that's not on offer this time. The hospital isn't officially encouraging its employees to go.
"It is a pressing need, there's no doubt," says Miriam Aschkenasy, deputy director of global disaster response at the hospital's Center for Global Health. "But institutionally there's a hesitation because there are a lot of considerations."
Considerations like the amount of time staffers would need to take off. For most disasters two weeks is sufficient. But to work on Ebola, staffers need two weeks just to get trained. Then four weeks to work in an Ebola treatment unit, then three weeks off work to monitor their symp-toms -- just in case.
Just as importantly, Aschkenasy says, hospital officials worry there's no infrastructure to take care of their staff if they get sick -- with anything, not just Ebola. And there's no easy way to get them to another country for treatment.
"The institution is primarily responsible for the liability of their staff," she says. "It looks really bad if your staff goes off somewhere and something really bad happens to them." And yet, she says, she still hopes medical workers across the United States will step up.
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More than 300 beds in a matter of weeks. That's the plan for construction of the "world's largest Ebola treatment unit" in Liberia, says Rajiv Shah, head of USAID, the U.S. Agency for International Development. It's one of 18 facilities going up in Liberia alone.
The czar of the federal agency for foreign aid took a break from his tour of West Africa, where he is monitoring the progress of American interventions, to speak with Morning Edition's Rachel Martin.
"The extraordinary engineering and design is something to watch," Shah said. Special piping for chlorinated water has been installed, so health care workers can quickly spray down others wearing personal protective equipment after they've treated a patient. Incinerators are be-ing built to dispose of medical waste safely.
A 25-bed "world-class" hospital explicitly for international healthcare workers should also
be complete in Monrovia, Liberia, by the end of October, said Shah. Construction of Ebola fa-cilities is also underway in Sierra Leone and Guinea, he added. Shah concedes that the number of active Ebola cases will continue to rise before it drops significantly, but he sees hopeful signs: Liberians have already changed their behavior in ways to keep the disease from spreading.
"People are not shaking hands. They're bumping elbows," said Shah. "Everywhere you go, you wash your hands with chlorinated water before walking into any building."
This is Shah's first trip to the region since the outbreak. Asked for his impressions, he spoke of the families who've lost a love one. "It is extraordinarily challenging to lose a member of your family to Ebola. It's even more challenging to know that as that person is passing away, they are a contamination risk, and therefore, the natural human instinct to hug your child is no longer safe. You can just feel the palpable sense of tragedy and that reality," said Shah.
And he had great praise for the healthcare workers. "There are hundreds ... coming in from around the world," he said. "They are the heroes of this response. Our goal is to just sup-port these heroes as much as possible and scale this effort as quickly as possible so we tackle Ebola at its source."
John F. Kennedy Memorial Hospital is the largest public hospital in Liberia. It has a trauma unit, a maternity ward and an outpatient clinic that serves hundreds a day. But there's one illness that the facility won't treat: Ebola. JFK is not equipped to treat or contain it if it gets in-side their wards.
A new triage unit in the driveway detects patients with the virus and sends them to a dedi-cated Ebola center. Like most hospitals in the capital Monrovia, the government-run JFK shut down in July after several of its prominent doctors died of Ebola. The hospital reopened in Au-gust -- with major changes to keep the virus out.
"If we miss and a patient get up here and it's real Ebola, it's helter-skelter," says Dr. Wvennie MacDonald, the general administrator. "The staff panic, they run, we got close down. We got to spray. It's an economic cost. You got to rebuild morale."
All patients now come through one gate, says MacDonald. Those who arrive on foot or motorcycle are sent to a triage station under an awning to the left of the driveway. Anyone in a car or ambulance is screened by a nurse at the vehicle. If there's any suspicion that someone is sick with Ebola, a doctor is called immediately.
Even when patients make it past the initial triage, they're still treated as possible carriers of Ebola. The cleaning staff wears impermeable raincoats, face masks, hoods and thick rubber gloves even in the tropical heat. The midwives don full protective gowns -- some even wear goggles -- just to take vital signs during routine checkups.
The neonatal ward has been split, with babies from women who are known to the hospital staff in one area and those who are unknown, and thus suspect, in another. MacDonald says in this time of Ebola the staff have to be incredibly careful -- all the time. Keeping staff vigilant is one of the challenges as this epidemic drags on.
"It's very tough because you forget," says Helena Gbalzeh-Suah, a nurse at the hospital. "You easily forget."
Health care workers need to constantly check their protective gear and make sure they don't come in contact with the bodily fluids of anyone. "It's not something you say, 'OK, I got to go back and correct it,'" Gbalzeh-Suah says. "You're dead. That's what we are dealing with."
This hospital knows this all too well. Last week the head of the obstetrics and gynecology department died of Ebola. Earlier JFK also lost three others to the disease, including the hospi-tal's top HIV physician, the director of the emergency unit and a physician's assistant. Everyone who works at the facility is terrified of Ebola, says Gbalazeh-Suah. But she views this as a good thing because it keeps them on their toes.
MacDonald says screening patients rigorously before they can enter the hospital remains the institution's best defense. But she says the screening needs to be more than just taking pa-tients' temperature. They may not have a fever because they've taken over-the-counter medica-tion.
So the hospital has come up with a different strategy. "Listen to the story," MacDonald says. "What I've told my staff is let them tell you their story in the Liberian vernacular. You em-
pathize: What's wrong? How can I help you?"
She knows that if health workers simply go through a checklist, asking patients if they have a fever or if they've been vomiting, "everything is denied."
I am an infectious disease physician at Boston Medical Center, and I serve as the Director of Infection Control at National Emerging Infectious Diseases Laboratory. This summer I went to Sierra Leone for a month to serve at the Kenema Hospital as a physician in the Ebola Treat-ment Unit.
The first day in Sierra Leone, the day of arrival, all of the flight attendants put on gloves shortly before we landed. As I walked out into the customs halls in Lungi Airport in Freetown, every wall was plastered with posters providing information about Ebola.
We were asked to complete a health questionnaire and fever check -- one of dozens I would receive during my time in the country. In the dark rainy night, the water taxi that carried us from Lungi airport to Freetown seemed otherworldly. Seeing my co-clinicians, who had ar-rived a few hours before me, at the hotel was a big step in helping me reorient to the purpose of my journey.
George, Kate and I needed to make it to Kenema in time to overlap with the outgoing team. It's a three and a half hour trip from Freetown. On the way, we saw many children on the streets. It was a weekday. We wondered why they were not in school. Our driver told us school had been canceled because of Ebola. In fact, there were no weddings, no baptisms. People had stopped gathering. In between small villages, the lush green landscape was dotted with occasion-al burned buildings, remnants of the civil war.
We arrived in Kenema and met the outgoing group at dinner. Their camaraderie was pal-pable. I could see how these relationships were critical. In this environment, you depend on the people you work with for your safety. It was hard not to feel like the new kid.
We were somber at hearing about the continued dearth of healthcare workers and the pa-tient load. On the first day at the treatment unit, we followed a clinician who'd been there for a while, learning about the available resources and the patients currently receiving treatment.
Every thing I did that first day took a moment of reflection. OK, I am entering an ETU for the first time; I am now seeing and caring for an Ebola patient for the first time. I am carefully coming out of my personal protective equipment (PPE) for the first time in the field -- a time I am statistically most likely to infect myself. But after every first time, anxiety turned into re-solve, and practice made the process routine.
The following days were a blur. Hard work, the smell of chlorine, the heat. Each day started with a group breakfast, then the 10-minute drive to the hospital, a rush to get all the in-formation, including overnight deaths, transfers, lab results. Although being inside the PPE was physically unbearable because of the heat, I felt a sense of urgency every morning to get into the unit.
At the hospital, we each collected our PPE. We counted out the six items every day, a trick to develop muscle memory: gloves, Tyvek suit, hood, face shield, mask, rubber boots. It was our shield as we walked into battle. Or so it felt.
In pairs or as a team, we entered the low-risk area. Sullivan, the man at the entrance, al-ways had a ready smile as he sprayed down our rubber boots with bleach solution. We entered the donning tent. I saw so many people in that tent and early on wondered who they were. They were porters, hygienists, food servers.
In the donning tent, we put on the equipment, checked each other out to check the suit for gaps and tears. I soon came to realize that you can spend an entire day with someone in PPE and not know what they look like. It's why we put our names on our aprons, the top layer of the PPE, so we'd know each other's identity.
And then we entered the high-risk zone. First it was the suspect wards, for patients who fit the case definition of Ebola and were waiting for a test to confirm the diagnosis. We called it the "Annex." which housed both those who will test positive and those who had symptoms similar to Ebola but may turn out to have another disease, like malaria. It was our daily challenge to sepa-rate the sick from those who are less symptomatic.
The minute we entered the high-risk zone, people were waiting on the landing of the ward
entrance to ask what their test results were. Beyond the Annex were the confirmed ward and re-covery wards. In the confirmed ward, the healing and the dying mingled.
The hallways were filled with people at varying stages of their disease, from those on the road to recovery to those in the throes of their illness, coming to terms with the gravity of their situation. Many of these patients had already seen family members going through this and in some cases die.
They were dehydrated, confused, looking at you, looking past you, too weak, bed bound, barely able to use the waste bucket next to their bed. Every day, it felt like you were putting out fires, trying to address the most urgent needs before your own resolve started to fade, your face shield fogged up, your mask was so filled with sweat you couldn't breathe.
In the ward, the patients whose tests shows they have recovered from Ebola have to be discharged so that we can make room for the new patients who have positive tests. Suspect pa-tients who don't have the disease have to be quickly discharged so they do not contract the infec-tion while in the ETU. By the time you got out in the afternoon, wondering where the past few hours had gone, you were spent.
On a typical day, I'd do either three two-hour shifts in the suit, or two three-hour shifts. The other six hours of the day I'd deal with case management and collect data to help with clini-cal care and keep tabs on this epidemic. And recover from the stress of being in the Ebola ward. After getting out of the PPE, I would hydrate like a marathoner. The idea that I'd put my body through that again, let alone later that afternoon, seemed unreal. But then my mind started to equilibrate with the return of the fluid and the electrolytes and I'd became strong enough to ig-nore the complaints of my body.
Midday, we'd regroup and have lunch and share information about this patient or that. Some days I felt good coming out after a morning in the ward, as if I had made a difference and put things in order.
Then three hours later I'd go back in and faced chaos. It's as if fate was laughing at me. New patients had arrived who had not been tested; some were deathly ill. Patients who looked good only a few hours ago had taken a turn for the worst. Some even died in the interim.
The whole process started again: helping one human at a time and providing for immedi-ate needs, while trying to keep my mind focused through the constant, "Doctor, doctor" requests coming from all directions.
One of the largest ethical dilemmas working in this environment was striking a balance between personal safety and patient survival. At times I'd have to leave the ward because the electricity was out and it was unsafe to continue working. It didn't matter that I had a child in my hands who needed my help.
Logically, healthcare worker safety is paramount because loss of workers will further stymie the response to the epidemic. But in reality, in that moment, as the provider for that pa-tient, it will be the hardest choice you will make. At night, after our 12-hour days, we tried to spend some time with each other, decompressing. We tried to keep the mood light, joked, shared stories from home.
We wondered if any of us could truly explain to others back home what this experience is really like. I tried to talk to family but exhaustion, and fear of revealing my own anxieties about contracting the disease, made me keep the conversations short.
And then I'd do something silly, something that went against all logical understanding of this disease. I cleaned all major surfaces in my room with bleach wipes as if I was creating an invisible fortress of cleanliness, leaving the day behind me, and got into bed to fall asleep. If there are things that I wish I could share with others about my experience, they would be:
1) Most people can survive this disease. In the patients who presented to us in time, and who stayed hydrated before and during treatment, the mortality was under 40 percent. This is despite the lack of human resources and medical and lab supplies.
My favorite days were days when we discharged patients from the recovery ward. One of my co-clinicians asked the children in recovery to come up with a "recovery song," a celebration in anticipation of when their tests will turn negative and they will leave this place for home. The children would greet him every time he returned with the song.
After a couple of days it was clear the adults also were partaking in this ritual. It was the most powerful thing I have ever witnessed, sometimes sitting outside the unit, hearing songs
from the recovery ward. We can improve the mortality rate by just improving the number of hands helping and by giving patients the best basic supportive care. The early and continued pro-vision of oral rehydration solution can help as well.
2) Every day I was there someone thanked me, thanked me for taking care of these pa-tients. This encouragement was so important. I have provided care to patients in setting with lim-ited resources, but generally as providers, we don't have to worry about our own safety. We place an artificial barrier between ourselves and the patients, as if we are somehow immune to the dis-eases around us. It is an important part of being able to provide care.
That façade is harder in this setting, knowing how many healthcare workers have died be-fore us and seeing so many young people present with minimal symptoms and full faculties, and then watching them become so debilitated that they cannot get out of bed to defecate. Then to see that a hundred times over breaks the most stoic of dispositions. The words of encouragement were so important in light of the loss inside the unit.
3) Inside this ward is a microcosm of humanity and almost all of it is kindness and self-lessness. A sick patient one bed over might offer to translate your words if the person you are interviewing doesn't speak English. Healthier patients advocate for those who have taken a turn for the worst. Women adopted orphans and cared for them if the children's own mother had died. People gave each other encouragement from across large ward rooms.
Inside the wards, you found some of the most committed nurses from the local staff. De-spite losing so many of their own, having their morale decimated, nurses like French, who be-came the head nurse at Kenema ETU, spent hours upon hours, day after day providing compas-sionate care.
On one of my last days at Kenema, I found an old man in a triage tent who was extremely ill. I was giving him oral rehydration and kept asking him his name: "Sir, tell me your name so I can see if you have been tested already." He kept mumbling and when I could finally hear what he was saying repeatedly, it was, "I am nobody. I am nobody." I will never forget that moment.
This epidemic is not one of nameless, faceless individuals living far away. It is a story of family members who expressed love and grief at losing their loved ones. It's about strangers who provide kindness at the right time to others. It's about children who wandered alone through the halls of illness but then made it out and survived.
It's about those who died in my hands despite all my efforts. It's about the healthcare workers who buried their own and are continuing to work. It's about entire communities that have been debilitated by this epidemic and about countries that will see an entire generation af-fected by it. It's about putting your fear aside and doing what you know is needed in that mo-ment. It's about you and me and what we do next to eradicate the epidemic.
Behind the hellish Ebola epidemic ravaging West Africa lies an agent that fittingly em-bodies the mad contradictions of a nightmare. It is alive yet dead, simple yet complex, mindless yet prophetic, seemingly able to anticipate our every move.
For scientists who study the evolution and behavior of viruses, the Ebola pathogen is per-forming true to its vast, ancient and staggeringly diverse kind. By all evidence, researchers say, viruses have been parasitizing living cells since the first cells arose on earth nearly four billion years ago.
Some researchers go so far as to suggest that viruses predate their hosts. That they essen-tially invented cells as a reliable and renewable resource they could then exploit for the sake of making new viral particles.
It was the primordial viral "collective," said Luis P. Villarreal, former director of the Cen-ter for Virus Research at the University of California, Irvine, "that originated the capacity for life to be self-sustaining."
"Viruses are not just these threatening or annoying parasitic agents," he added. "They're the creative front of biology, where things get figured out, and they always have been."
Researchers are deeply impressed by the depth and breadth of the viral universe, or vi-rome. Viruses have managed to infiltrate the cells of every life form known to science. They in-fect animals, plants, bacteria, slime mold, even larger viruses. They replicate in their host cells so prodigiously and stream out into their surroundings so continuously that if you collected all the
viral flotsam afloat in the world's oceans, the combined tonnage would outweigh that of all the blue whales.
Not that viruses want to float freely. As so-called obligate parasites entirely dependent on host cells to replicate their tiny genomes and fabricate their protein packages newborn viruses, or virions, must find their way to fresh hosts or they will quickly fall apart, especially when ex-posed to sun, air or salt.
"Drying out is a death knell for viral particles," said Lynn W. Enquist, a virologist at Princeton. How long shed virions can persist if kept moist and unbuffeted -- for example, in soil or in body excretions like blood or vomit -- is not always clear but may be up to a week or two. That is why the sheets and clothing of Ebola patients must be treated as hazardous waste and sur-faces hosed down with bleach.
Viruses are masters at making their way from host to host and cell to cell, using every possible channel. Whenever biologists discover a new way that body cells communicate with one another, sure enough, there's a virus already tapping into exactly that circuit in its search for new meat.
Reporting recently in Proceedings of the National Academy of Sciences, Karla Kirke-gaard, a professor of microbiology and genetics at Stanford University School of Medicine, and her colleagues described a kind of "unconventional secretion" pathway based on so-called au-tophagy, or self-eating, in which cells digest small parts of themselves and release the pieces into their surroundings as signaling molecules targeted at other cells -- telling them, for example, that it's time for a new round of tissue growth.
The researchers determined that the poliovirus can exploit the autophagy conduit to cun-ning effect. Whereas it was long believed that new polio particles could exit their natal cell only by bursting it open and then seeking new cells to infect, the researchers found that the virions could piggyback to freedom along the autophagy pathway.
In that way, the virus could expand its infectious empire without destroying perfectly good viral factories en route. The researchers suspect that other so-called naked or nonenveloped viruses (like the cold virus and the enteroviruses that have lately plagued children in this country and Asia) could likewise spread through unconventional secretion pathways.
For their part, viruses like Ebola have figured out how to slip in and out of cells without kicking up a fuss by cloaking themselves in a layer of greasy lipids stolen from the host cell membrane, rather as you might foist a pill down a pet's throat by smearing it in butter.
According to Eric O. Freed, the head of the virus-cell interaction section at the National Cancer Institute, several recent technological breakthroughs have revolutionized the study of vi-ruses.
Advances in electron microscopy and super-resolved fluorescence microscopy -- the sub-ject of this year's Nobel Prize in Chemistry -- allow scientists to track the movement of viral par-ticles in and between cells, and to explore the fine atomic structure of a virus embraced by an antibody, or a virus clasped onto the protein lock of a cell.
Through ultrafast gene sequencing and targeted gene silencing techniques, researchers have identified genes critical to viral infection and drug resistance. "We've discovered viruses we didn't even know existed," Dr. Freed said. And that could prove important to detecting the emer-gence of a new lethal strain.
Gene sequencing has also allowed researchers to trace the deep background of viruses, which, at an average of a few billionths of an inch across, are far too minuscule to fossilize. In fact, viruses were first identified in the 19th century by size, as infectious agents able to pass through filters that trapped all bacteria.
Through genomic analysis, researchers have identified ancient viral codes embedded in the DNA of virtually every phyletic lineage. The unmistakable mark of a viral code? Instructions for making the capsid, the virus's protective protein shell, which surrounds its genetic core and lends the viral particle its infectious power.
"It turns out there are not many ways to make the pieces that will snap together into an ef-fective package," said Dr. Enquist, of Princeton. "It's an event that may have occurred only once or twice" in evolutionary history.
Viruses are also notable for what they lack. They have no ribosomes, the cellular compo-nents that fabricate the proteins that do all the work of keeping cells alive. Instead, viruses carry
instructions for co-opting the ribosomes of their host, and repurposing them to the job of churn-ing out capsid and other viral proteins. Other host components are enlisted to help copy the in-structions for building new viruses, in the form of DNA or RNA, and to install those concise nu-cleic texts in the newly constructed capsids.
"Viruses are almost miraculously devious," Dr. Freed said. "They're just bundles of pro-tein and nucleic acid, and they're able to get into cells and run the show."
"On the one hand, they're quite simple," Dr. Enquist said. "On the other hand, they may be the most highly evolved form of genetic information on the planet."
Viruses also work tirelessly to evade the immune system that seeks to destroy them. One of the deadliest features of the Ebola virus is its capacity to cripple the body's first line of defense against a new pathogen, by blocking the release of interferon.
"That gives the virus a big advantage to grow and spread," said Christopher F. Basler, a professor of microbiology at Mount Sinai School of Medicine. At the same time, said Aftab An-sari of Emory University School of Medicine, the virus disables the body's coagulation system, leading to uncontrolled bleeding. By the time the body can rally its second line of defense, the adaptive immune system, it is often too late.
Yet the real lethality of Ebola, Dr. Ansari said, stems from a case of mistaken location, a zoonotic jump from wild animal to human being. The normal host for Ebola virus is the fruit bat, in which the virus replicates at a moderate pace without killing or noticeably sickening the bat.
"A perfect parasite is able to replicate and not kill its host," Dr. Ansari said. "The Ebola virus is the perfect parasite for a bat."
The woman didn't even seem close. So Barh sent her home and told her to return to the maternity ward when her contractions started. Barh was expecting her in a couple of days, maybe a week.
"But to our utmost surprise, the very next day," she says, "that woman was rushed on our ward, bleeding profusely."
The woman was in full labor. The midwives raced to deliver the baby. "Right after the fetus came out, that woman started bleeding from all over," Barh says.
"We did everything we could, just to save her life. But even with a blood transfusion, she ended up dying."
The baby died, too. And it was only then that Barh and her team learned the truth about the woman's medical history: Two of her relatives had died of Ebola. If a person can get treat-ment, he or she has nearly a 40 percent chance of surviving Ebola.
But for a pregnant woman and her fetus, Ebola is almost a death sentence. One small study found a fatality rate around 95 percent. The woman invariably passes the virus to the fetus. And the fetus dies before labor, or it's born and dies shortly after. The devastation doesn't stop there. Both the baby and the woman's amniotic fluid are flooded with Ebola virus -- and are highly infectious.
"After a few days, the midwife who did that delivery came down with Ebola," Barh says. "She spent 21 days in a treatment center. It was only by the grace of God that she recovered."
Many other midwives haven't been so lucky. Right outside Barh's office is a whiteboard. There are about three-dozen photos taped on it. At the top, it says, "Nurses and midwives who have died during the Ebola crisis."
Not all of them caught the infection from pregnant women, but in Liberia, you hear the same story over and over again: Someone got Ebola while trying to help a pregnant woman in trouble. When a woman is bleeding, minutes can mean the difference between life or death for the baby and mom, Barh says. "Sometimes it doesn't even give you ample time to put on your gloves. ... That alone is so dangerous for the midwives."
With so much blood and so much bodily fluid involved in deliveries, even doctors with access to protective gear are getting infected. That's how the American doctor Rick Sacra got Ebola in August. Sacra, who is now recovering in Worcester, Mass., was helping pregnant wom-en at a hospital outside Monrovia called Eternal Love Winning Africa, or ELWA.
"Sacra was being very cautious," says ELWA's assistant director, Dr. John Fankhauser.
"But it's also just very risky. What we consider our two riskiest places are the OB ward and the operating room."
The problem, he says, is that women who are miscarrying often have bleeding and cramp-ing, like someone with Ebola. So it's very difficult to tell the difference. The risk to health care workers is so high that many clinics in Liberia refuse to treat pregnant women. Hospitals have closed their maternity wards.
The ripple of effects of that breakdown in the health care system could be more cata-strophic than Ebola itself. ELWA is one of the few health facilities in Monrovia where a woman can deliver her baby. The midwives there now wear full Ebola suits -- gown, gloves, face mask, goggles -- during every delivery. And they get sprayed down with chlorine after a shift, just like in the Ebola clinic.
"So far, by the grace of God, we haven't had another infection," Fankhauser says. "But all we can do is take great precautions. We can't stop caring for patients."
Even as careful as Fankhouser was, he is now back in the U.S., under quarantine, after possible exposure to Ebola. So far, he's had no symptoms. And many midwives across Liberia have stopped caring for patients, says Ester Kolleh, the lead midwife at ELWA. They've quit or stopped coming to work. "Everybody is afraid of catching Ebola," she says, "because most nurs-es who caught Ebola died."
Around that moment, a nurse walks by in the hallway of ELWA's OB ward. In her arms is a baby who isn't moving. Kolleh explains what happened.
"Last night we received three ladies," she says. "They had been in labor one week, two weeks. Nobody to help them."
The three women had gone from hospital to hospital in Monrovia. They were turned away at each one. By the time they made it to ELWA, it was too late for their babies. "All of them had stillbirth," she says. "They couldn't get help from anyone. The babies died before they came. Now we have three dead babies in the delivery room."
The United Nations Population Fund says the problem is widespread across Liberia, Sier-ra Leone and Guinea. Maternal death rates are climbing. And tens of thousands of women -- and their babies -- could die in the region over the next year unless more maternity wards reopen and ERs start seeing pregnant women again, the agency predicts.
Kolleh says that's why she's not quitting, no matter the danger. "We keep doing it because we have to do the work," she says. "We have to save lives."
And bring tiny new ones into the world, too.
BBEEAATTIINNGG TTHHEE OODDDDSS NNOOVV 2211,, 22001144 One reason the Ebola virus is so terrifying is that it's so lethal. Researchers estimate that
the strain circulating in West Africa is killing upward of 70 percent of those it infects. Even among those getting care, as many as 64 percent are dying.
But some doctors in Sierra Leone say it doesn't have to be that way. An Ebola treatment facility in the capital of Freetown claims to have improved the odds of survival -- with few re-sources and little money.
Sierra Leone's government set up the Hastings Ebola Treatment Center in some class-rooms at a former police training academy. When we visit the facility, it's payday, and the work-ers who are lined up to get their wages seem particularly animated.
But the lively atmosphere also reflects the broader mood here. In the midst of a lot of bad news about Ebola -- a surge of new infections, and way more patients than space to treat them -- the workers at this facility feel like they're finally having some success.
After losing about 40 of their 70 patients in the first week the facility was open, in mid- September, the staff at the facility realized they needed a new strategy for dealing with the dread-ful disease.
"We said, 'no, this cannot continue -- we need to do something,' " says Dr. Santigie Sesay, who coordinates treatment at the center. At a brainstorming session, staff zeroed in on a key problem: dehydration. People with Ebola are wrecked with diarrhea, they vomit, and some may bleed.
"So we said, 'if we can replace the fluids that are being lost, we can definitely help these
people,' " Sesay says.
The usual way to replace fluids is with an intravenous drip, but it can be dangerous to in-sert a needle into an Ebola patient. All it takes is one prick to infect a health worker. Plus, run-ning IVs takes careful monitoring. So Sesay was advised against IVs when the treatment center opened.
"During our training, we were told that we are not supposed to go into the vein," he says. Still, the staff at Hastings resolved to give IVs a try -- with their most experienced nurses
inserting them. To date, none of the workers have gotten infected. And the effect on patients has been dramatic, Sesay says. It's difficult to pinpoint survival statistics for any one center when the overall number of patients is small and the outbreak is still unfolding. But based on the data so far, he says, Hastings' death rate is way down.
"Out of every 10 patients, four will die, and six will come out," he says. Sesay also has noticed another effect: The medical staff at the center has realized that the
patients now have a fighting chance.
"Everybody has become very, very enthusiastic," he says. The staff started interacting with the patients more, even helping the weakest ones eat.
"We started talking to the patients. We even started bed-baths," Sesay says. "We became so motivated, and things changed drastically."
Isatu Koroma, who cleans the inside of the ward, says she's been pulling for an older pa-tient -- a woman who reminds her of an aunt of hers who had died recently of Ebola.
"I fell in love with her," Koroma says. "Because I love her like my aunt." The woman was in bad shape when she arrived. "She was so sick, so weak," Koroma says. "I go to her, encourage her: 'Please, you have family. You have your daughter.' "
Now, that woman is among about 60 patients who have been moved to the recovery area, just across the yard, where a worker is calling out the names of people who soon will be released. The moment is bittersweet. These people have survived Ebola and get to go home, but a lot of them have lost close relatives.
One women in the area lifts up a baby high into the air. He's tiny. "This baby has no moth-er or a father," the woman says. Both of the baby's parents have died of Ebola. The woman has been caring for him, even though she doesn't know the little boy's name.
"I call him Mohammed," she says. The woman has two children of her own waiting on the outside. Her kids, at least, will be getting their mom back soon.
Ebola is on the rise in Sierra Leone's capital of Freetown. Just this week, 234 new con-firmed infections were reported, and every day hundreds of residents call the emergency line to report more possible cases in their neighborhoods.
To deal with the surge, the nation sends health surveillance teams into the community to investigate the alerts, visiting up to five homes a day to check on residents. The junior member of one team is Osman Sow, a young man with a wisp of a beard and a serious manner.
Sow clutches a sheaf of papers with the names and addresses of today's list of suspected Ebola sufferers. He jumps into the back of a green pickup, and soon he turns off the thoroughfare onto a rutted dirt road.
The pickup passes mud brick huts with corrugated metal roofs. Ebola has hit this place hard, and the evidence is everywhere. Sow points to a boarded-up house.
"As you can see, there is nobody there," he says. "There were 11 inhabitants. Nine of them died."
The team passes a few more boarded-up homes before reaching its destination, a narrow hut, steps from the ocean. A middle-aged man shuffles out and takes a seat on the front porch. He looks haggard. Sow and his team stand a good distance away, and they can barely hear him.
The man points to his throat and says, "It's hurting." Two of his children recently died of Ebola. Now, says Sow, "he and his wife have developed the signs and symptoms of the disease, and also their grandson."
Sow fills out paperwork for an ambulance pickup, and says his part in this is done. "Well, we have given the report to the command center," he says. "It's left for the ambulance to come take them."
But when -- or even whether -- the ambulance will arrive is another story. Sow says right now, Freetown's treatment centers don't have enough beds for all the people falling sick. Patients stay in their houses and die, waiting for an ambulance that doesn't come.
"So therefore, when we come there also the second time, they will not be happy," he says. "More than 80 percent of the places, they blame us, every day."
Still, he sees signs of improvement. Earlier this day, the team stopped at a house where two sick children had been left alone after their parents and nine other relatives died of Ebola. The ambulance showed up while the team was still there.
Team leader Tomeh Bangura is an older man, a fatherly figure to the others. He says the image of those kids being led out by a nurse in protective gear is still haunting him.
"The eldest, I think she was 8," Bangura says. "She was in the house, locked herself in the house. And it was not possible for us to open. So luckily when the ambulance came the nurse was in her [personal protective equipment]. We sprayed the place and took the child from the house into the ambulance. I felt so bad."
A half-hour drive takes the team to a community health clinic, where the workers meets with a pregnant woman and her husband. They ask her to sit in a plastic chair in the yard. Her name is Kadiatu Kargbo. She's dressed in a lace skirt and sparkly flip-flops, and picks at her fin-gernails while Sow calls out questions from his list.
"First I eat, then I vomit," she answers. Sow finds "vomiting/nausea" on his list and checks the "Yes" box. He thinks she probably
has malaria, but based on her symptoms she'll need to be tested for Ebola. Kargbo's husband looks worried.
What if she gets exposed to people who do have the disease while she's waiting at a hold-ing center? "I don't want to take this girl and to mix her with other sick people," he says. "We don't know what her status is yet."
The day grows dark, and at the final stop, a hut shaded by tall trees, the village head man calls for a 15-year-old boy, Alusine Banguar, to come out. The head man says he's been calling the emergency line about this boy for three days.
The boy walks over slowly, wearily, and sits on a tire in his yard. They go through the checklist. A large crowd gathers, and starts piping up with complaints. It seems another 15-year-old -- this one a girl -- recently died of apparent Ebola in a house nearby. Her relatives are sup-posed to be under quarantine, but they've been walking around freely. One of the youth leaders asks for police enforcement.
Bangura explains that his team has nothing to do with quarantines, and the crowd starts to calm down. Still, as Bangura heads back to the pickup, he looks tired. The scenes he's witnessing on this job are alarming him. Last night, he says, he had a serious talk with his wife.
"I advised my wife, on no account should any of my children step out of this compound," he says. "They should stay indoors. I said, 'Ebola is becoming very serious. Very, very serious.' "
And when you have children dying, he adds, "it's very pathetic."
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Wencke Petersen came to Liberia in late August to do what she normally does for Doctors Without Borders in hotspots all over the world -- manage supplies. But the supplies she was meant to organize hadn't arrived yet. So she was asked to help with another job: standing at the main gate of the walled-in compound, turning people away when the unit was full.
For five weeks, she gave people the bad news. Petersen says there are some people she will never forget -- like the man who sat in the rain all day, waiting. "We had no space -- he just asked for a place to lie down," she says. "At the end of the day I could take him in ... he died two days later."
Other people died in front of the gate, still waiting to get in. Petersen finished that stint in Liberia in early October; now she's back in the country again. These days there are fewer cases in Monrovia -- but still many cases in rural areas, where people can't reach an Ebola treatment unit.
So this time, Petersen is no longer at the front gate; she's back at her old job, managing supplies.
TTHHRROOUUGGHH TTHHEE EEYYEESS OOFF AA LLOOCCAALL HHEEAALLTTHH WWOORRKKEERR NNOOVV 2244
Even as encouraging reports come out of Liberia that Ebola cases appear to be leveling off or declining, it's not the full story. In recent weeks, there was a major outbreak of Ebola in scat-tered villages of Rivercess County, in the remote, southeastern part of the country where Lorenzo Dorr, a Liberian health worker with decades of experience, is helping to improve local health systems.
Goats and Soda introduced Dorr back in September. He's been working with Last Mile Health, known in Liberia as Tiyatien Health, a nonprofit started by a Liberian-born physician that trains and deploys community health workers in remote areas.
That kind of approach is more critical now than ever -- not only to keep Ebola in check but also to prevent future epidemics. Liberia's southeast has been relatively unaffected by Ebola -- but this outbreak, with 24 deaths so far, shows that even far-flung areas are not immune. Dorr spoke with Goats and Soda from Cestos City, the Rivercess County capital.
On Oct. 21, a lady who came to the county from Monrovia fell sick. She didn't seek care from a health facility. Instead she relied on traditional medicine. She sought treatment from drug peddlers and traditional healers. She eventually died. News came to the city. The traditional council spokesman in the area, when contacted by the Rivercess County Health Team, instructed the community that nobody should touch her body, but the people didn't listen.
Before the response team from the county health team arrived to the community, they bathed and buried her. A few days later they all started to get sick and began dying, one after the other. There's a patient now who is positive and his wife is showing signs and symptoms, their child is a probable case. They are living in their home in a town about five hours' drive from Cestos City. We want to get them out but have not been able to do so. The roads are so bad that the ambulance could not access the community when it tried to move in. The bridges were bro-ken.
A total of 94 contacts were identified. Twenty-three who were considered strong contacts were sent to the Ebola treatment unit in Monrovia. Currently, 71 contacts are being monitored in the community. But some unidentified are still on the run, and they could infect other people. So there might be other deaths in the days to come.
It's 100 miles away from Cestos City to the affected area, five hours' drive, so the mood is quiet. Not many people have a real sense of the gravity of what is happening because they are so far from it. But health workers know the gravity of the issue. The level of care has not increased since the outbreak. There is no proper isolation center here. They use the hospital emergency room for isolation. That is not recommended. An isolation unit should have its own sanitary fa-cilities. It should not be sharing latrine facilities. So there is still a huge gap in the system. And not only here, but also similar gaps are present in other parts of the country.
Food security has become a challenge as farming activities have been abandoned. A tradi-tional healer reported that because of fear of Ebola, people are not going to work on farms. Peo-ple normally are working in groups, they get together -- but in this time people are not moving from place to place. They stay in one place as the entire region has been temporarily quarantined.
The food situation is very serious in the areas that are worst hit. Food security is also a problem for those held in isolation because of suspected Ebola. The logistics to move food to isolated areas is rather difficult. Even when food is available, delivery is affected by lack of good roads. Even if there are vehicles, they can't move in because of broken bridges.
The dry season has begun to set in, and the rainy season is fading away. But the roads are still bad. I just feel for those being affected. Even to get an ambulance to pick up the sick contin-ues to be a very big challenge. An MSF truck could not pass on the road, it could not enter a town and had to unload the truck to get materials into the town. The villages are scattered, with-out roads, so contact tracing is also difficult. You can't easily communicate due to lack of access
to the mobile phone network in the affected area and surrounding towns and villages.
There are a lot of misperceptions about the Ebola response process. The community has its own perceptions about the whole Ebola issue. Initially people didn't listen to health workers' advice. They didn't understand what it means to protect yourself. Some didn't believe the disease exists, not until a lot of people began to die.
Many people believe health workers are carrying the Ebola virus. In one of our daily health coordination meetings held at the county health team in Cestos City, it was reported that some community members were resentful because of the new thermometers, they point it to your head and people said it's like an Ebola gun stuck to your head and will give people Ebola. It's the first time this kind of thermometer has been used in Liberia and some people didn't understand what it was. It takes so much to help people understand when you are doing something that is unusual. People are gradually accepting the use of the thermometer. These are some of the chal-lenges we health care providers are faced with.
Our concern is to help the Rivercess County Health Team prepare to respond effectively. The team is very hard-working, very passionate about the Ebola response and about bringing this situation to an end. We're going to roll out infection prevention control training to healthcare workers. And we will be training community health workers on contact tracing.
For community health committees, midwives, traditional and prayer healers, drug peddlers and other key stakeholders at the community level, we'll do training on contact tracing, infection prevention control and establishment of referral systems from the community to medical facili-ties.
We are training health workers how to break the transmission chain. This will be an im-portant step at this critical time. There is a lot more to be done. It needs a concerted effort.
NNPPRR
NPR has done some remarkable reporting from west Africa. The segments below consists of selections from various reports. Personally I've found their reporting to be highly evocative of the aura of the Ebola affected regions that I experienced in Liberia. The human face of the epi-demic is captured with an explicitness that leaves me filled with both admiration and sadness. What an excellent work NPRs reporters and others that I've remarked on earlier, have done in documenting the facts of this horrible epidemic. The world needs to know.
The following story reminds me of a number of my memorable trips looking for an "in-ternet cafe" or "video club" in Monrovia, a place where I could purchase some time for online access.
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The NPR photo below seems like an exact depiction of the typical cafe. They were gener-ally one room structures, dark and hot. The primary attraction was a television set on which Eu-ropean soccer games were shown. A large group of noisy young men would be packed into the room infront of the TV. The computer, where I'd do my business if lucky, was located at the back of the room, stuffed into a corner.
The computer itself was usually an idiosyncrasy, a machine that's difficult to describe. But as long as it worked, I could get online for thirty minutes to send emails to family. This task did require a lot of concentration, first of all to ignore the heat, then the shouting, and then the density of people crowding in on you.
During one internet session, the crowd watched Manchester United take on Chelsea while I sat in the corner at the back trying to peck out a message to the other world. What made it espe-cially tough was that the brick wall behind me, had openings broken into it. Potential patrons of the cafre who couldn't afford the admission, crowded against the other side of this wall and peered through the holes watching the game.
They were no less rowdy and loud that everyone else. Their heads were about three inches behind mine and their shouting went directly into my ears. the brick wall usually had openings broken into it through which nonpaying customers outside the club could watch the soccer match
yelling directly into my ear from a few inches away. Reminded me of scenes from one of my fa-vorite movies "Into the West."
The tough part of all this, isn't what I've just noted. The tough part is watching these pro-
fessional soccer players behaving worse than little children who don't know how to walk proper-ly. At the slightest touch, a grown man in a socceer uniform will be flung to the ground, where he curls up into a ball of writhing pain. I thought they were pathetic. Even children aren't that delicate.
Who am I to complain though. I'm in favour of changing the name of soccer, at least as played in the professional leagues in Europe, to "husha husha." Husha husha is the game we played as children when husha husha, we all fall down.
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The sun has set in Liberia's eastern border town of Ganta, and the red dirt roads are humming with motorbikes and boomboxes. As Ebola starts to lose ground in the West African country, life is slowly returning to normal. Liberia's nightlife, which stalled after officials de-clared a state of emergency in early August, is gradually picking up. And the hangouts where Liberians pay a small fee to watch soccer are once again packed with fans.
At Justina's, a club in the center of Ganta, about 30 young men have come to watch the Champions league matches. Real Madrid is beating Ludogorets, and Arsenal just put the ball past Galatasary's keeper.
Liberians call these places "video clubs." They're kind of like a sports bar, only there's no beer served and no barstools. Young men -- and it's almost all men -- come here to support their squads. The dimly lit hall is filled with rows of plastic chairs in front of mounted TVs. People are passionate about soccer here. Plus, since so many are out of work, watching games is a way to pass the time.
When the government announced a state of emergency, "everyone was afraid to come to-gether," says Alberto Fong, who's standing outside Justina's during halftime. "Sitting here [in these clubs] is very dangerous so everyone was trying to observe the rules."
That means avoiding human contact, staying away from large gatherings and washing your hands with diluted chlorine before entering public buildings. That's part of the way Liberia was able to cut the weekly number of new Ebola cases from around 400 down to under 100. Be-cause of this trend, the state of emergency was lifted a month ago. But health officials say com-placency could stop the progress. So the government recommends taking precautions.
"My ministry is telling people that if you want to go to video clubs you first need to ob-serve safe measures we have put in place," says Isaac Jackson, Liberia's deputy information min-
ister. "Wash your hands."
After all, Ganta sits right across the border from Guinea, where the outbreak started. But there's no chlorine bucket in front of this video club. Fortunately, Fong came with his own hand sanitizer. "Just in case I touch someone," he says. Not everyone is as prepared as Fong, and these sticky, sweaty video clubs are jammed with people.
Just down the street from Justina's is the Arsenal video club. It's pretty lax inside. Men sit shoulder to shoulder on wooden benches. Most of them seem comfortable -- but not everyone wants to go in. Emmanuel "Good Boy" Gbormie is taking no chances, so he sits outside.
"Very, very not safe, it's an interactive environment [and] there's no bucket to wash hands," he says. "So for me personally, I need to protect myself." For Gbormie, that's more im-portant than cheering his team on in the video club. He says he'll wait for his friends to come outside and tell him who's won.
While I was in Liberia I attended many of these IMS meetings. I got to know many of the participants, especially the Liberian members. The NTY article below, in my opinion, mischarac-terizes the nature of these meetings. During these meetings, dealing with an intractable, deadly problem, there was an extraordinary sense of representatives of major organizations working to-gether for the good of the afflicted countries. Liberian representatives such as Dr. Dolo were staunch advocates of cutting to the chase and getting things done.
They had a difficult row to hoe and they were stalwart champions for their nation and it's people. Their concerns, for example, about NGOs and other groups from well known institutions conducting research and collecting patient data without the basic restraints that every other na-tion in the world would apply to such situations, was right on and did a service to their country. That's just one example of many.
Leaked minutes, clearly, don't accurately convey the actuality of the IMS meetings. I sus-pect that when all is said and done, many of the representatives to the IMS will be recognized by their countries for the valuable service they conducted on behalf of Liberians.
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The global response to the Ebola virus in Liberia is being hampered by poor co-ordination and serious disagreements between Liberian officials and the donors and health agencies fighting the epidemic, according to minutes of top-level meetings and interviews with participants.
Even now, three months after donors began pouring resources into Liberia, many con-firmed cases still go unreported, countries refuse to change plans to erect field hospitals in the wrong places, families cannot find out whether their relatives in treatment are alive or dead, health workers sent to take temperatures sometimes lack thermometers and bodies have been cremated because a larger cemetery was not yet open.
The detailed accounts of high-level meetings obtained by the New York Times, the most recent from Monday, lift the veil on the messy and contentious process of running the sprawling response to Liberia's epidemic, one that now involves more than 100 government agencies, charities and donors from around the world. Despite these problems, with help from donors, Li-beria, one of the three most afflicted west African countries and with the highest death toll, has seen new cases drop to about 20 a day from about 100 a day two months ago.
Experts attribute that to fearful Liberians touching one another less, more safe burials of bodies and distribution of protective gear to health care workers. However they also warn that cases are now holding steady and could explode again. Participants at the meetings of the Inci-dent Management System – which replaced the National Ebola Task Force – said the atmosphere should not be characterised as chaotic or bogged down in bickering, instead calling them "colle-gial" and "effective", although one who spoke on condition of anonymity described "showman-ship and political posturing".
Senior officials of the Centers for Disease Control and Prevention who attended – Dir. Frank J Mahoney and Dir. Kevin M De Cock – said in an email that there were "differences of opinion – accompanied by passionate discussions".
At Monday's meeting, De Cock cited serious logistics problems, including regular hospi-tals that could not separate out Ebola patients, counties with no ambulances and even tempera-ture takers with no thermometers. On November 12th, the representative of the UN secretary general complained that "hundreds" of vehicles had been made available but there was always a shortage. Asking where they were, he added: "The recipient also has to be accountable, just as
the donor."
The support documents also indicate that there is no national plan for Ebola survivors – ei-ther for reuniting them with their families or for using them to do nursing tasks because they are thought to be immune. A report on the issue reads: "The current and planned work presented by the partners and government for survivors can be characterised as fragmented and lacking in scope, scale, comprehensiveness, evidence base and survivor-driven programming."
US military helicopters ferrying doctors to remote areas were forbidden to fly back not only patients but even blood samples; recently, samples from a village had to be walked to a road four hours away. At Monday's meeting, according to the minutes, De Cock called this "unac-ceptable", adding: "This has to change this week."
Dir. Hans Rosling, a Swedish epidemiologist and consultant to Liberia's health ministry, said the helicopter order came "from somewhere in America."
In an interview, he cited problems not listed in the minutes. One Asian and two European donor countries were insisting on building new Ebola field hospitals in Monrovia, where hospi-tals have empty beds, rather than in remote counties where beds were desperately needed, he said – they insisted because they announced those plans two months ago; the national case count was not reported for two days recently because the government employee compiling it went unpaid and stopped working.
The minutes of the Incident Management System were made available along with Power-Points and other documents by an expert who said the disorganisation of the Ebola effort should be made public. The meetings are usually chaired by Tolbert Nyenswah, the deputy health minis-ter, and include representatives from the Centers for Disease Control, the World Health Organi-zation, the World Bank, the UN Mission for Ebola Emergency Response, numerous UN agencies, the US Agency for International Development, the US Army, Doctors Without Borders and med-ical, aid or military representatives from many other countries.
Nyenswah and other ministry officials could not be reached for comment; Rosling has worked with the ministry since October. The minutes make it clear that accuracy of the national case count is shaky. On November 5th, Rosling said, "We are absolutely sure that we cannot be sure about the data."
In an interview, he said that to improve reporting of cases, he gave a $13,000 Swedish government grant to "a chronically honest church lady" to buy mobile phone scratch cards for health officials in remote areas. The CDC is bringing satellite phones to areas lacking mobiles service. Despite problems, he added, the response was better than he had hoped. He compared it to Dunkirk, the hasty 1940 evacuation of British troops from France, which he described as "chaotic, but a success".
In the minutes, Liberian officials regularly complain about the donors and the donors ar-gue back. On November 12th, James Dorbor Jallah, the task force's deputy manager, said: "Peo-ple will sit in DC or Geneva and want to direct what is happening here."
The health minister, Dr. Walter T Gwenigale, backed him up, complaining that "the UN and other agencies got their money before the ink was even dry", while, he said, a group run by a Liberian pastor to teach rural people about Ebola "has not gotten one cent".
On Sunday, President Ellen Johnson Sirleaf replaced Gwenigale without explaining why, but said he would remain an adviser. Dir. Emmanuel T. Dolo, Sirleaf's youth adviser, com-plained that the donors were "showing a level of disrespect" by judging Liberian community groups by "harsh standards" and "western standards."
At the same meeting, Nyenswah, the deputy health minister, pointed to his government's "team leaders" and warned: "Partners in the room have not been engaging them and involving them in strategy – but you have to."
A representative of the UN Children's Fund replied that the local pastor needed to prove he could do the work. Two days later, Shiyong Wang, the World Bank representative, confirmed that UN agencies had received nearly all their money and that the Liberian government had re-ceived only 7 per cent of the $23 million allotted to it.
However, he said, the government had not produced required documentation – not even, for example, names of dead health workers whose families awaited compensation. He criticised the government's "overly complex and bureaucratic approval process", including three signa-tures on each document. Rosling said the three signatures were an anti-corruption measure.
Beneficiary lists were hard to produce, he said, when Liberians had children whose births were often not officially recorded. And it was "arrogant," he added, for donors to, for example, assign contracts to operate field hospitals without health ministry permission.
The November 12th meeting appeared to end on a bitter note, with Nyenswah telling eve-ry agency to document within 48 hours what people it had and what their jobs were. "If you don't give us this list," he concluded, "you are not allowed in this meeting."
The meeting of November 14th opens with Nyenswah reminding scientists not to do re-search without permission from a government ethics review board. On November 17th, Dolo complains that "there are a lot of people in this room who never contribute anything to this meet-ing."
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There's a new phase of Ebola in Liberia. Epidemiologists call it pingponging. Back in March, the disease was found in the rural areas. Then as people came to the capital to seek care, it started growing exponentially there. Now, some sick people are going back to their villages, and the disease has pingponged to the rural areas again. So that's where we're headed -- into the hot, thick jungle of Liberia to investigate a new Ebola hotspot.
Our day with the team of Ebola investigators starts at 3 a.m. The team has been told there's a woman with Ebola out there who hasn't been treated. She could be spreading the dis-ease. We drive five hours from Liberia's capital, Monrovia, and stop at a small, rural clinic that looks something more like a house with a few rooms and no electricity.
The team has people from the World Health Organization, the African Union, Doctors Without Borders and the Liberian Ministry of Health. At the clinic, the head nurse says she has also heard the rumors of a sick woman. But the nurse hasn't seen her. The nurse shows us a hand-drawn map on the wall of where we need to go to find the woman. Our destination, she says, is a village called Fermaneeta.
It's the last village at the end of a thin black line on the map. A thin black line means the only way to get there is to walk, down a long footpath into the jungle. Fours hours each way. As we walk, Mutaawe Lubogo from the African Union says there are several options for the woman if she has symptoms. If she's very sick, they can help set up a community quarantine in the vil-lage and try to come back the next day with supplies. If the woman is still in the early stages of Ebola, she can walk back to the clinic, where an ambulance can pick her up.
Lubogo is from Uganda and worked on the 2007 Ebola outbreak there. "You're talking to someone who has seen it before," Lubogo says. But in Uganda, Ebola was confined to the rural areas, and that's where it ended. In Liberia, there's pingponging.
"If I fall sick, I have to come to the rural area, where I have my parents, to my family to
give me care," Lubogo says. This is how pingponging works, he says. People go back and forth between the city where there's commerce, and the village where there's family. And a few of
them take Ebola with them.
Out where we're walking, a village is basically a clearing in the jungle, with 10 or 20 huts. The walls of the huts are made of mud; the roofs are made of branches and leaves. Each village has a well, a fire pit for cooking and small fields nearby to grow food.
Each village is about an hour from the next one. At the fourth one, we find a clue. The team meets a man who people say is a traditional healer -- he rubs herbs on sick people. He sup-posedly cared for the woman who's rumored to have Ebola. The team lists off the names of peo-ple who have tested positive for Ebola. The man says he knows a lot of them. But he denies that he's a healer. He won't even admit that he has touched or treated any of them.
This is called contact tracing. If you're doing it in Dallas, Texas, you get addresses and phone numbers. Out here it's different. We leave the man and keep on walking. We finally make it to the village where the woman is supposed to be.
NOTE: On a second hike, the team found the woman who was rumored to have Ebola in Bomota, her home village. So far she has shown no symptoms. According to the team members, she admitted she was hiding on a farm the day that we came.
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The Ebola outbreak started in rural areas, but by June it had reached Liberia's capital, Monrovia. By August, the number of people contracting the Ebola virus in the country was dou-bling every week. The Liberian government and aid workers begged for help.
Enter the U.S. military, who along with other U.S. agencies had a clear plan in mid-September to build more Ebola treatment units, or ETUs. At least one would be built in the ma-jor town of each of Liberia's 15 counties. That way, sick patients in those counties wouldn't bring more Ebola to the capital.
But it's taken a long time to build these ETUs; most won't be done until the end of the year. And now the spread of Ebola changing -- clusters are popping up in remote rural areas. So building a huge treatment center in each county's main town may no longer make sense. Two hours outside the capital, the Army's 36th Engineer Brigade just finished erecting an ETU last week. Lt. Abraham Richardson shows me around, first giving me a tour of the triage building where all patients will arrive.
Then he leads me to four giant white tents inside what health workers call the "hot zone." "That's where all the confirmed cases will be," Richardson says. Each tent will house about 25 patients. This is what the military is good at: landing in a place they've never been and building stuff.
But some say the size of the ETUs is a problem. Because it's taken so long to build the centers, their relatively large size is no longer useful, says Dr. Darin Portnoy, who's with Doctors Without Borders. He's just finished caring for two sick children at one of the organization's orig-inal ETUs back in Monrovia.
"ETUs are not needed right now at the same level," he says. "Right now the construction should be scaled down -- fewer beds."
"Take the amazing capacity that has been brought to bear and direct [it] elsewhere," he adds. By elsewhere, Portnoy means remote rural areas, where, sometimes, the only way to reach people is by walking for hours or taking a canoe. He says big international donors should support so-called rapid response teams that go out, find those hard-to-reach people and set up small treatment centers where they actually live.
"Just because you have a plan ... doesn't mean you have to continue on that plan," he says. The U.S. has started to scale down its plan, building only 15 ETUs instead of the 17 origi-nally planned. Some ETUs will now have 50 beds instead of 100. And instead of sending 4,000 troops to West Africa to build facilities and train health workers, the military says that number will now be closer to 3,000.
The military is also helping to locate Ebola cases in remote areas. Just last week, says Maj. Gen. Gary Volesky, who commands the U.S. forces in Liberia, the military gave a team of epidemiologists a ride in a helicopter to a remote village north of the capital to find Ebola vic-tims.
But Volesky says he wants to know the military has an exit plan, and that someone else
will take over the jobs that the U.S. troops have been doing. A few hours north of the capital, at one of the busiest ETUs in Liberia, custodian John Jameson shows us the burial ground full of fresh mounds of dirt. "Three, four, five burials a day," he says.
The ones buried here were those who could make it to the ETU. Health officials say many more people are getting sick and dying in remote rural areas, which means Ebola will keep spreading.
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Each day, a nurse comes to this clearing outside Taylortown, Liberia, to sing a song of mourning, preparing the space for the next burial. So far nearly 100 people are interred here.
There's a clearing in the jungle in central Liberia that now serves as an Ebola burial ground. Every day, a woman who works as a nurse in the nearby Ebola treatment unit, or ETU, changes from her scrubs into traditional dress, walks into that clearing and sings a song of mourning.
The song is meant to prepare the space for the dead. There is a burial every day. So far, nearly 100 people have been buried in this clearing. Sixteen are from one village about 45 minutes away, a place called Taylortown, or Taylata in the local dialect.
To understand how Ebola came to the village, how it spread in the village and how it eventually ended in the village is to understand how the epidemic might end in Liberia, and what will be left behind.
Taylata is a collection of mud brick houses with thatched roofs built on either side of a single gravel road. The trouble came a little more than a month ago. A man in the village named Stanley had a 16-year-old son who was living in Liberia's capital, a few hours away.
The son was staying with relatives. Three of them died in a row. People said one died in childbirth, another from grief. They didn't say it was Ebola. Stanley went to get his son and bring him back to the village. The two went to work in the sugar cane fields. On the third day, the son was achy and tired. Then he started getting really sick.
The thing is, Stanley had been trained by the county to recognize Ebola and notify au-thorities. But when his own son got sick, he tried to treat the boy himself. "He had information," says village youth leader Peter Gasho. But "he hid that information."
So other people in the village called the county health team to come meet with Stanley and his wife. When the meeting began, the parents told the team their son had what villagers call a "leopard problem." What they meant was that someone had turned into a leopard and tried to kill their son, and that's why he was sick. Our interpreter, Siatta Scott Johnson, tells us it's a common belief in Liberia, that witchcraft can make you sick.
But in the time of Ebola, this belief can be dangerous. We walk down that main gravel road in the village to Stanley's house. The front door is closed. Outside are abandoned wooden benches in a circle. This is where Stanley's son died. Peter Gasho says Stanley's son died on a blanket as villagers surrounded him, sitting on the benches. He says everyone was touching the boy, practicing "country medicine" by rubbing herbs all over his body, giving sympathy.
That sympathy would eventually take a tragic toll. A person who is dying of Ebola is very contagious. The first to get sick were the boy's siblings. Finally, the father, Stanley, admitted it was Ebola. And finally, county health officials went into action. They took the sick siblings to the ETU. They documented everyone who'd been in contact with the family. They quarantined the village. Then they came back to check every day. The next people to get sick and die were the women who'd tried to help Stanley's son.
We keep walking through the village and meet an 11-year-old girl, sitting alone next to the cook-fire. Her grandmother cared for the sick boy and later died of Ebola. Now, people in the village are afraid of the girl and her 10-year-old brother. When we ask who stays with the chil-dren at night, she answers with one word. "Nobody."
After the caregivers, like the girl's grandmother, got sick, the people in their houses got sick. One strong young guy got Ebola from his mother. He was visiting from his final year at the University of Liberia. Peter, the youth leader, says he was the hope of the village, "the most im-portant person in the town."
Stanley would not admit that his son had Ebola. Villagers were angry at him for hiding the truth and looted his home. After this student died, people in Taylata started looking for
someone to blame. They started pointing fingers at Stanley. Stanley got Ebola, too. But he sur-vived. His wife and four of his children died. Stanley was released from the ETU last week. But he hasn't come back to the village. People have already looted his house and threatened to burn it down.
Stanley calls people in the village sometimes. Nobody knows exactly where he is. We tried to reach Stanley. We called and sent messages. Then he switched off his phone. From this one case, this one boy, 30 people got Ebola in Taylata. Twelve survived. One of those survivors is a teenager named Romeo. Romeo returned home after being declared Ebola-free. After his re-lease, people in the village crowded around him to welcome him back.
A county health official presented Romeo to the village with a document saying he's Ebo-la free. Villagers clapped. Romeo still has red eyes, bloodshot from Ebola. He's lost so much weight, his pants are falling down. He listened to his iPod during most of the health official's presentation. Afterward, people ambled back to their houses or to the main road to gossip.
Ebola is gone from the village. But the market is still closed; people still rely on interna-tional aid organizations for food. It'll be awhile before things get back to normal. In the coming days, the village will have a memorial for the people who died.
As of today, there are only two people from Taylata left in the county Ebola treatment unit. There, the Liberian doctors and nurses who work with these patients will do what they do every day before they start their shift. They will stand in a circle and sing a prayer.
VVOOAA DDEECC 44
This article is by Carly Learson who spoke with Ebola survivors to ascertain how they were coping and what type of aid is now required to assist those left behind. She visited the Libe-rian village of Banjor and a refugee camp known as Voice of America (VOA). Photo credit is to Carly Learson.
In many of the areas of Liberia that were hardest hit by Ebola in July and August, there are fewer new cases, but no-one has been left unaffected. In Banjor, a slum on the outskirts of Monrovia, and VOA, an internally displaced persons camp, the community is struggling to care for hundreds of orphaned children. They face stigmatization and financial problems. Many are severely traumatized.
"We didn't know what to do," community chairman A. Ishmael Kamara said. "In one house an entire family died, and the bodies were inside for two days. Others had fever and we didn't know if it was malaria or Ebola – we still don't know. We called 4455 (the Ebola hotline) but there was no answer. People were being turned away from hospital. People wanted to run away but we weren't allowed to leave the area."
The entire area was quarantined for several weeks during the Ebola crisis. In total, 111 people died in Banjor – 48 men, 32 women and 31 children. Amjad Kiazolu was one of the community members who organised a local Ebola taskforce with the help of the World Health Organisation and NGO Samaritan’s Purse. The taskforce consisted of five members from each block. He described the pain of watching friends and relatives suffer.
"This disease is spread by love and sympathy," he said. "When a loved one is suffering, the natural response is go to them and comfort them. At the beginning so many people could not watch their children suffer, they cared for them and then they too got infected."
The Ebola taskforce members described how they worked non-stop visiting households, spreading the message that Ebola was real and educating people on how to prevent infection. "We knew that we had to get people to wash their hands with bleach," Mr. Kamara said. "But then their skin started peeling off and they thought they had skin cancer. We went around to make sure the mix was right, otherwise they'd stop using it." For a community that relies on the market, the Ebola crisis hit the local economy hard. "Banjor was a no-man's land," Mr. Kamara said. "No-one wanted to talk to us."
During the worst part of the crisis, the area was quarantined. Some local merchants brought food, but it was hard to get enough. Even now that the crisis is over, Banjor has a bad name and its people are stigmatised when they go to sell in the market. For families that relied on selling in the market on a day-to-day basis, losing weeks of income ate up their entire savings.
Katumu Konneh's son-in-law was the first Ebola victim in VOA camp. He became sick one day, but instead of being taken to hospital, the factory where he worked offered him two months' salary to go home instead. Several family members were infected after caring for him.
They all died. Their houses are now locked until they can be thoroughly sterilised.
Ms. Konneh was married, but her husband had three wives and she decided life would be easier on her own. She has two school-aged daughters who she supports by selling food in the street, or selling toilet paper at the entrance to one of the community's two toilet blocks. Since Ebola came, she has not been able to sell much because no-one has any money to buy extra food.
Her family eats rice and leaves they collect. Hawa Musa lived in a house with her hus-band, brother, sister and brother-in-law, all their children and several renters. She received rental money, as well as income her husband would bring in, and was able to live well and care for her family.
Now, of 25 people living in the house, 17 have died from Ebola. She is dealing with the grief of losing her husband, two daughters and many relatives and friends, and at the same time has lost all of her income. All her renters have died from Ebola, and no-one will move into her house now. She has also taken in children who have been orphaned, and in total is looking after 10 children with the help of her brother, sister and mother. "All I can do is pray," she said.
In another house live three women, Bindu Sonnie, and sisters Dudu and Satta Kromah. All three lost their husbands to Ebola. Now, in addition to their own children, they have taken in 27 children from other families whose parents died. Dudu cares for a three-month-old baby, and her exhaustion shows in her face. "I don't know how we can keep doing this," she said as she fed the baby a bottle.
"We're just living day to day, we have no income since our husbands died. It's a struggle to feed all these children." Bindu Sarmavalu's daughter Hawa was one of just a few nurses in Banjor, and was one of the hundreds of health workers in Liberia to die from Ebola after helping patients. Hawa's husband Mohammad looked after her and became infected, but the children were kept away.
Above: Dudu Kromah' is looks after ten children, many orphans including a 3-month-
old baby.
With the help of the community, Mohammad, was taken to an Ebola Treatment Unit. Af-ter several weeks, he got better. Hawa had been supporting the entire family, including Moham-mad's mother. Now, through programs run by the Government and NGOs, Mohammad is em-ployed to train new health workers who are being brought in to help with the crisis. But Bindu said the whole experience had been heartbreaking. "I feel the pressure, it's so much I can't breathe," she said.
The UNDP will soon start its early recovery programs and initiatives that include direct cash transfers and support to county level government administration to help people get their lives back on track.
Ebola has "orphaned" about 2,000 children in Liberia, health authorities say. Some chil-dren are being looked after in two shelters in the country's capital, Monrovia. Reuniting the kids with their relatives, or finding them foster homes, can take time.
These are kids who have come into contact with sick people but aren't showing signs of Ebola themselves. The children must be monitored for 21 days -- the cycle of the Ebola virus -- in a care center to ensure they are also not infected, says Anthony Klay Sie of ChildFund Libe-ria, the nonprofit running the shelters.
"Children are placed in a group of three. If a child starts to show signs and symptoms of Ebola, that child is immediately isolated," he says. "The entire essence of this center is to help break transmission of the virus within family settings."
So far, the shelter has recorded five cases of Ebola among the children, Klay Sie says. Three died, and two have survived. Those who are healthy have to go through a two-stage pro-cess before they can be reunited with family. Once they've completed the first observation peri-od, the children move to a second shelter.
After at least 21 days there, they are eligible to go to their new home or to extended fami-ly. Today is that day for 18 children. Cars wait outside the shelter as Sienna Wisseh, assistant director of Liberia's Family Welfare Division, gives out orders. She is helping to supervise the children's departure.
"The six bags, they go in the car with the children -- and a blanket and a bucket, every-thing," Wisseh tells the staff.
Each child is given clothes, toiletries and a blanket, along with about 55 pounds of rice and cooking oil. They're also given colorful mattresses, Klay Sie says. All of the items are part of the reunification packages provided by the government and other nonprofits.
"Normally, children who come from a family that had an infected person, their belong-ings are all burned," Klay Sie says. "So upon their return, they may find it difficult to start life over."
Some of the children have been here for as long as two months, like the Togba sisters: 13-year-old Lovetee and 12-year-old Tray. Both are wearing delightful bobble hairstyles and broad smiles. But these turn to nervous, sorrowful looks as the girls remember the loved ones they've lost to Ebola.
"We were a family of seven," Lovetee remembers. "My father, my grandma, my auntie, my uncle and my brother died."
Lovetee calls the uncle who died her Pa, or her father, because he was the one looking af-ter the Togba sisters and paying their school fees.
"The first time I came to this place, I was sad because the place was strange to me," Tray says through Siatta, a Liberian journalist who was with us. "It was just my sister and I."
It's a bittersweet moment, says Hawa Sherman, the supervisor of the children's shelters. "I'm very happy, and I'm sad because over the months we have got so used to them," she says. "We are happy because they are going to be reunited with their families, and we will also miss them, too."
"They need more love, definitely," Sherman adds. "Losing your parents is hard. It's very hard to take, so we need to give them more love."
When the cars set off, there's a short delay as a couple of the colorful mattresses, heaped onto the roof of one vehicle, get caught on the gate. First stop is Jacobstown, a neighborhood at the end of a dirt road on the outskirts of Monrovia. After the cars arrive, Ebola survivor Makutu Jabateh squeals with delight as she hugs her newly returned 5-year-old daughter, Mabana Konneh.
More than 800 children have been resettled in Liberia to date, UNICEF says. The children have to be reintegrated into the community.
"So many times, you notice that the communities are afraid of the children," says Sienna Wisseh of the Family Welfare Division. "So many communities don't even want to associate themselves with the children."
Stigmatization of Ebola survivors and those whose family members have died from the
virus has been a problem in Liberia. Jacobstown's community leader, Oscar Wisseh Sr., has a brief word with the small, happy gathering.
"We do not stigmatize the parents, and we will not stigmatize the children," he tells them. Then papers are signed and certificates delivered. Ebola survivor Weah Korveh, who lost six family members, has just been reunited with her 3- month-old son, Sekou Dukely.
She starts to cry as she thanks those who have looked after her baby boy. "Thank you for taking care of my children," she says between sobs. "So many of my people passed away." Baby Sekou's mother breaks down as she talks, but she gets her message across.
If you think the fight against Ebola is going well, here's a grim new number: 537. That's how many new infections were reported in Sierra Leone in the past week. It's the highest weekly tally in any country since the West African outbreak began.
International governments and aid groups have scrambled to open Ebola treatment centers in the country. But, because of safety concerns, many of these centers are accepting only a frac-tion of the number of patients they were built to serve.
" In the meantime, most sick people are being directed to makeshift, government-run cen-ters. Some of these are simply schools or other government buildings re-purposed into a "com-munity care center" -- a place for people with Ebola symptoms to be isolated.
Bai Marrow Lamina Ngbathor, who heads up a chiefdom of several hundred villages in Sierra Leone's rural north, is helping transform a school into one of these care centers. The facili-ty is a lot more basic than the full-fledged treatment clinic that is supposed to serve this District--but which is only treating about ten patients while it scales up. That place was built with funding from foreign governments, including the U.S., and has a sophisticated in-ground plumbing and sanitation system.
Here at the school, workers are digging a big hole in the ground. "Those are the toilets for the suspected cases to use," Lamina Ngbathor says. The treatment offered at the school center will also be a lot more limited -- medication to bring down a fever and rehydration salts that pa-tients can drink with little help or supervision. In contrast, at some treatment centers, patients are getting intravenous drips for fluid replacements and direct attention from staff.
Still, though, Lamina Ngbathor and his team have stood up this community care center in a matter of days. He walks into a room where there are 11 metal cots. "This place was a class-room," Lamina Ngbathor says. A chalkboard on the wall still has a lesson written on it. "My name is Hawa. I'm a girl. I'm 4 years old," Lamina Ngbathor reads off the board.
These community care centers -- and larger holding centers -- were originally conceived of as temporary triage outposts. Health officials intended them to be places where people who might have Ebola could be isolated while they waited for an Ebola test result. If the test came back positive, then a person would be sent onto a proper treatment facility.
But right now, there's no better place to go. So sick people are getting stuck at these triage centers, many will likely dire here. Effectively, the main function of this place seems less to help sick people than to prevent them from infecting others.
"If we allow those sick to be in the community, Ebola will spread," says Lamina Ngbathor. "And all of us will die."
But a few miles down the road, at a similar but larger holding center, I Dr. Corrado Can-cedda with the aid group Partners in Health is trying to change this approach. He says this idea that so many Sierra Leoneans have to die while the international response scales up is unac-ceptable.
Cancedda asks, "Why should people here get a lower standard of care than Americans or Europeans? Everybody deserves the same level of care. That should always be our goal and our guiding principle."
So Cancedda has begun turning this existing holding center into a full-fledged treatment facility, with IVs. He's also bringing in medical workers from overseas and trainers in a matter of days, not weeks. And Cancedda totally rejects the idea that Ebola has to be such a deadly dis-ease. "Ebola kills so many people here in Sierra Leone because there's not the resources to take care of patients properly," he says.
As soon as possible, he wants to start using lab tests to monitor organ function and tweak
electrolyte levels -- the things that American and European hospitals have been doing to support their Ebola patients.
"Let's bring the tools, and then the mortality rate will go down," Cancedda says. "There's no reason why it couldn't be 20 percent, or 10 percent, if you diagnose patients early enough be-fore they're sick."
The key to getting there, Cancedda says, is to maintain a sense of moral outrage -- the conviction that as long as people are dying, what you're doing is never enough.
Liberian President Ellen Johnson-Sirleaf hopes to ring in the holidays with an ambitious goal: no new cases of Ebola in her country by Dec. 25.
"We believe we had to set a target that gave our people hope, a target that would make them more committed to taking all the precautionary measures," she says. "Yes, it's called ambi-tious, but sometimes you have to take a risk in being ambitious."
If anything, the recent drop in Ebola cases is a hopeful sign. The outbreak has killed more than 3,000 people in Liberia, and at its height, the West African nation was reporting the most new cases of the virus per week. But at one point last week, the Liberian Ministry of Health re-ported that in the country's largest Ebola hospital -- equipped with 250 beds -- there were only eight patients. Yet while numbers are falling in the capital Monrovia, new outbreaks have been popping up in remote areas, which could reverse the progress. That's one of the biggest challeng-es to hitting the target, Johnson- Sirleaf tells us. The battle, she says, is far from over.
Once you get to zero cases, how do you keep it there? Now, it's strengthening our health system to prevent a recurrence. It's key and that's not
something we're waiting to get to zero to start on. We already have a 10-year plan to strengthen our healthcare facilities by training our workers [and] by upgrading the services in our clinics and hospitals.
Some might say you're overambitious that Dec. 25 will be the date for no new cases. Overambitious is the story of my life. I never stop doing that. And so they expect that of
me. I say my challenge is to work toward it. I have no guarantee that I will be successful, but I'll work at it.
What if Liberia doesn't hit that target? There's no great issue on that. If, for any reason, between now and the target date we
haven't been able to control [the outbreak], we will be the first ones to admit that and to say, well, we did set a target, but these conditions have changed it. Cross-border movements will make a big difference. We have porous borders, so as long as you have problems over there, we'll do what we can, but you know -- that's our target [and] we will work at it. There's no magic to it.
How do you deal with the problems of the borders between Liberia, Guinea and Sierra Leone that can easily be crossed?
We do that through coordination – exchange of information, best practices, good exam-ples. Our coordinators of our three countries will be holding a meeting in Freetown [capital of Sierra Leone] early next week. At the highest political level, I talked to President Koroma [of Sierra Leone] and President Conde [of Guinea] regularly, just to [see] how they're doing, how we're doing.
So, that's the best thing we can do. We're talking about maybe common facilities on bor-ders, so that we have treatment centers that will be close to the borders. And if there are sick people on that side -- and we have extra beds -- then our service can be provided to them. Those are some of the collaborative arrangements that will help us work together toward common pro-gress.
Many people are saying that Ebola is the second civil war. We were facing an unknown enemy. In the war, you know where the gun is, you know
where the soldier is, you know where the rebel is. With this one, you just didn't know.
Have you had sleepless nights?
In the beginning I had sleepless nights because I was as fearful as anybody else. I did not
stop going around talking to people. I did not stop coming to work. But I had sleepless nights. Now? We are making progress, we're committed to [resolving] this problem. So I do not have sleepless nights anymore. I sleep. I am very pleased to go to bed and to sleep throughout the night, get up the next morning and face the problem again and go to work at it.
CCRRUUSSHH EEBBOOLLAA CCAAMMPPAAIIGGNN DDEECC 66
The soccer coach is giving his team a pep talk: "This is not an ordinary game," he declares as he paces in the locker room. "This is life or death. Ebola has defeated thousands in West Afri-ca. Its key strength is passing."
Clearly this is no ordinary pep talk. And it's no ordinary soccer coach. It's the British actor Idris Elba, who is playing the part in a new media campaign to send the right message about Ebola to the right people at the right time.
Elba himself has a link to the West African epicenter of Ebola. His dad is from Sierra Le-one, where the outbreak is still surging. He joined a group of high-profile African soccer stars for the campaign, called Africa United -- a play off a common name for soccer clubs -- think Man-chester United or DC United. The CDC Foundation, which works with the Centers for Disease Control and Prevention, is the mastermind.
The campaign features print and billboard ads, radio spots and videos. As the coach, Elba lays out the tactics needed to beat this opponent: wash your hands, don't touch dead bodies, get to a treatment center quickly if you have symptoms. The ads also offer encouragement and sup-port to beleaguered West African health care workers.
Some of soccer's biggest stars, including Yaya Toure, Patrick Vieira and Carlton Cole, de-clare on camera, "I'm no hero." Then Elba says the real heroes are the doctors and nurses who are battling Ebola. The message on the screen: "Trust your health care workers. They're there to help you."
Sierra Leone striker Kei Kamara is one of the soccer stars in the ad campaign. He tells Goats and Soda, "It's a project that's really, really important. ... We are using the campaign to educate the people not just in Sierra Leone but around West Africa to what's going on."
Kamara played last year in England and just signed with the Columbus Crew in U.S. Ma-jor League Soccer for the 2015 season. The last time he was in Sierra Leone was in June -- and there were a lot of rumors flying around about Ebola.
"Because of a lack of education, people did not really believe in it," Kamara says. "They thought it was just the type of news that would come by and then just go away."
Obviously Ebola didn't just go away. It has killed more than 6,000 people across the re-gion and continues to spread. Last week Sierra Leone reported more than 500 new cases. As a professional soccer player, Kamara travels a lot. But he's not planning any trips to his homeland -- he's worried he could end up being quarantined somewhere. Even traveling with the Sierra Le-one national soccer team has become a major hassle. In September the team went to the Ivory Coast and the Democratic Republic of the Congo to play in a qualifying round for the Africa Cup of Nations.
"How we were treated going to these countries, it wasn't easy," he says. "Actually it was kind of rough. Even though we are all living in Europe and America, they treated us as if we were traveling from Sierra Leone. We were delayed in airports for three to five hours. We were being checked basically breakfast, lunch and dinner to make sure we weren't bringing Ebola into their countries."
Kamara came to the U.S. as a refugee 14 years ago. Even now in America, when people hear he's from Sierra Leone, he gets a lot of raised eyebrows. People pull back. They ask nerv-ously the last time he was back there. He hopes that the celebrity power of Africa United will make it possible for him to return home soon with no worries about Ebola.
CCUUSSTTOOMMEERRSS AARREE WWAARRYY DDEECC 77
Ebola has had a brutal impact on the economies of three West African nations at the epi-center of the outbreak. In Liberia, the World Bank has more than halved projected growth for the nation, compared to what they predicted before the epidemic.
Ebola has killed more than 3,000 people in Liberia and, at the height of the outbreak, closed shops, businesses and offices. As the situation eases, many have now reopened -- but it's
still tough going. In downtown Monrovia, on Ashmun Street, a large, windowless, derelict build-ing -- a bank, locals say, and a relic from the civil war -- is still pockmarked with holes from mortar shells or some other artillery. Nearby, above a low building painted in greens, there's a hand-painted board announcing Mrs. Quaye's restaurant, with a map of Africa.
Mama Quaye, the restaurant's namesake, welcomes NPR reporters into her almost-empty, low ceilinged restaurant. The dining room is small and dimly lit. The gracious, elderly widow, wearing a pale green gown, matching elegant headtie and shawl, sits at one of three long wooden tables. There are seats for at least 30 people, but only one couple is lunching.
Mama Quaye throws her arms up in the air in desperation, saying Ebola has as good as wrecked her business. This restaurant was an institution in Monrovia before Ebola. Before that, it weathered Liberia's 14-year civil war.
"Before the war ... this was a very famous restaurant," Quaye says. "I had a lot of custom-ers. During lunchtime this place would be crowded. Sometimes I'm so frustrated I want to close the entire business down. How would my family survive?"
Mama Quaye's restaurant is in the heart of Liberia's capital, where it has served potato greens, cassava leaf stew and other Liberian delicacies for decades. The back-to-back civil wars, which began at the tail end of 1989, were bad, says Mama Quaye -- but with Ebola the situation is even worse.
"We're not making any business; we're only struggling for our lives," she says. "All I want to do is be alive. Now that Ebola has subsided we reopened, but we hardly get customers. As you see it is now empty, that's how it always is. Sometimes in the daytime we get two custom-ers and that's all."
Mama Quaye says people are afraid of catching Ebola by eating out. She says people pre-fer eating food they've cooked themselves instead of going out to restaurants. This makes her sad, she says, but admits that it is important that everyone is fighting to prevent Ebola.
"Because life is important; as long as we have life [there is hope]," she says. Despite the difficulties, Quaye continues to support more than 16 people in her family, which includes chil-dren in the family who lost parents in the civil war. She cares for and educates them as well.
"I'm taking care of them. So I have very a huge family," she says. At the restaurant, Mama Quaye points to an almost full tray of fufu, a Liberian staple food often made with flour made from the cassava plant. This batch has been cooking since the morning, she says, but no one has bought any yet. There's no business.
"I'm thinking now, what I will do?" she says. But Quaye says that at least the meals she prepares don't go to waste if there are no customers, because she serves the leftover cooked food to her family. A full meal costs about $2.50.
And then, as if to add to the troubles, a high-pitched lament floats over from behind the kitchen counter, filling the restaurant. As if it's all just too much for her, Mama Quaye's friend Zinnah Gray tells us she has lost a number of her family members to Ebola and that the virus is not just a sickness, but a war. If it kills one person, she says, it kills the rest of the family. Then she begins wailing, pouring her pain and her loss into the lament.
Mama Quaye looks over at her friend sympathetically. Like many others during this Ebola outbreak, the two elderly women have plenty of problems. But there's one bright spot: a custom-er walks in, and another has just finished his meal. Alfred T. Karngar says he works across the road and is a regular at the restaurant at lunchtime.
"She prepares good food here," Karngar says. "I actually have been eating here [since] before the Ebola crisis and I see nothing that would stop me from eating here."
Karngar says he observes all the health directives, including hand-washing with chlorinat-ed water when he enters the restaurant. He says he tries to keep himself safe from Ebola, and will continue to enjoy a good meal at Mama Quaye's.
Liberia still records 12 new cases each day, says Kevin De Cock, the doctor leading the Centers for Disease Control and Prevention's Ebola effort in Liberia. At least half are in the cap-ital Monrovia, a city of more than 1 million. There are also pockets of the virus in the country-side.
"We cannot rest until Ebola is eliminated," De Cock says. "Great progress has been
made, but elimination of the disease is not yet in sight." De Cock spoke with NPR about what still needs to be done. The interview has been edited for length and clarity.
Liberians seem to have a growing sense of optimism. What about you?
There's a great danger of complacency and accepting this [disease] as the new normal when, in fact, we are now at the same stage [in intensity of the outbreak] we were in late June, early July. Just a year ago, this situation would have been completely unthinkable.
What do you mean by complacency? Well, one of the effects of this epidemic has been that it's transformed the way the world
thinks about Ebola. We've always considered this an important infection, but a kind of isolated and exotic one. It was something one read about in tropical medicine textbooks. All of a sudden this disease [is] being discussed at the highest levels of international and U.S. governments, on the floor of the United Nations, at the Security Council. Really, it's a crisis in global health.
And yet ... there's a danger that when the epidemic becomes more invisible again, this [continual presence of Ebola] becomes accepted as the new normal. We cannot allow that to happen.
How worrisome are the pockets of transmission in rural areas?
What we're seeing are clusters erupting in different counties, somewhat unpredictably. About a third to a half [are] apparently initiated by somebody from Monrovia, having traveled -- and then locally spread. The country, with all of the international [agencies and organizations], is getting better at responding to these clusters, but they're all their own mini-outbreaks and each of them needs to be addressed and extinguished. And this is continuing to happen. So this is an on-going epidemic.
How realistic is Liberian President Ellen Johnson-Sirleaf's target of no new Ebola cases by Christmas?
It's an aspirational target, and such aspirations are to be encouraged and supported. We follow the data, [which] show that there is substantial transmission of Ebola still ongoing. And Christmas is pretty near, but we'll see what happens. The state of emergency has been lifted. There's discussion of reopening schools. All this is very positive, but one has to balance that with a false sense of security that this is all over. And it's not over.
Above: a young girl lies on the floor of an Ebola Treatment Unit,
The president's new initiative, Ebola Must Go, shifts the focus from building Ebola treat-ment units to mobilizing the community. Is this the right time for such a change?
made, but elimination of the disease is not yet in sight." De Cock spoke with NPR about what still needs to be done. The interview has been edited for length and clarity.
Liberians seem to have a growing sense of optimism. What about you?
There's a great danger of complacency and accepting this [disease] as the new normal when, in fact, we are now at the same stage [in intensity of the outbreak] we were in late June, early July. Just a year ago, this situation would have been completely unthinkable.
What do you mean by complacency? Well, one of the effects of this epidemic has been that it's transformed the way the world
thinks about Ebola. We've always considered this an important infection, but a kind of isolated and exotic one. It was something one read about in tropical medicine textbooks. All of a sudden this disease [is] being discussed at the highest levels of international and U.S. governments, on the floor of the United Nations, at the Security Council. Really, it's a crisis in global health.
And yet ... there's a danger that when the epidemic becomes more invisible again, this [continual presence of Ebola] becomes accepted as the new normal. We cannot allow that to happen.
How worrisome are the pockets of transmission in rural areas?
What we're seeing are clusters erupting in different counties, somewhat unpredictably. About a third to a half [are] apparently initiated by somebody from Monrovia, having traveled -- and then locally spread. The country, with all of the international [agencies and organizations], is getting better at responding to these clusters, but they're all their own mini-outbreaks and each of them needs to be addressed and extinguished. And this is continuing to happen. So this is an on-going epidemic.
How realistic is Liberian President Ellen Johnson-Sirleaf's target of no new Ebola cases by Christmas?
It's an aspirational target, and such aspirations are to be encouraged and supported. We follow the data, [which] show that there is substantial transmission of Ebola still ongoing. And Christmas is pretty near, but we'll see what happens. The state of emergency has been lifted. There's discussion of reopening schools. All this is very positive, but one has to balance that with a false sense of security that this is all over. And it's not over.
Above: a young girl lies on the floor of an Ebola Treatment Unit,
The president's new initiative, Ebola Must Go, shifts the focus from building Ebola treat-ment units to mobilizing the community. Is this the right time for such a change?
It's a balance now between continuing to address the acuteness of the situation [and] the longer-term commitment as the health system reopens. Hospitals begin to focus on the problems that have been neglected in these last few months -- you know, maternal health, tuberculosis, HIV/AIDS, malaria, etc. I think what the president is aiming at is that [the community] has to want a society that is free of Ebola. That it's not just a job for the Ministry of Health or the gov-ernment or the external partners -- communities have to be involved.
I personally believe communities have played a substantial role in the impressive decline in the epidemic, particularly in Lofa County [northeast, near the Guinea border]. We need that across the whole region. It's encouraging that the president is committed to this and is really try-ing to mobilize the people.
What's been different about the Liberian response vs. the response in Sierra Leone, where cases are still rising?
That's an interesting question because there was this perception that something special happened in Liberia. [The answer is] yes and no. Liberia did what we know needs to be done, which is you isolate the sick, you provide best treatment and safely bury the dead. You protect health care workers, base your response on data and do contact tracing. In some parts of the country, communities played an active role, particularly rural areas. So there's nothing special.
And yet on the other hand, the fact that they did it in a country that is among the 10 poor-est in the world is encouraging and impressive. I think in Sierra Leone, they're very reassured to hear that they're doing the right things but they accept that there needs to be increased intensity. And what I think has happened in Freetown [the capital] perhaps is that there's been somewhat of a slowness in isolating the sick [and] waiting for the right facilities to be in place when actually you can't wait. You have to use what you've got to do the best you can.
What's your advice? Press on. We need to continue with a vigorous response based on addressing Ebola as we
know how to do it -- with case finding, isolation of the sick, treatment and care of the sick and, very, very importantly at this stage, contact tracing. And, as the health care system reopens, pro-tection of health care workers.
Among the Ebola victims in New Georgia Signboard was the Kaifa family. "What hap-pened really was that the mother died, and the kids were too sick. We couldn't get near. We couldn't touch them," said community leader J.B. Walker Dennis. "The Ebola thing is very dreadful."
A relative visiting from another community brought the infection, Dennis said. Within days, the relative and his mother were dead, leaving six others alone and infected. "All of the sick, living children were lying on the porch vomiting, toileting on themselves," said Ophelia Ghartay, wife of the church's pastor. "We should not touch anyone that is sick. But we knew we could still do something."
And that "something" included basic support, like food and water; finding transport to take them to an Ebola treatment unit in Monrovia; and having church members visit the children while at the ETU. Dennis said New Georgia Signboard started a task force early in the outbreak and also held weekly educational gatherings at the church to inform people on how to keep safe.
"Don't touch anyone. Don't hug anyone. When people started dying, we started quarantin-ing their homes," he said. He said they got the guidance they needed from government Ebola safety messaging that blanketed radio and text messages.
"The Ministry of Health was always on the air telling us what to do," he said. All six kids survived, but with an uncertain future. Relatives would not take them in. So the community stepped up. The church rented a room for the kids. But things didn't go well. Fear of Ebola re-mains high, and survivors are stigmatized.
"People began to lash us," said Pastor John P. Ghartay. "What right do we have to bring the children into the community?" he remembers them saying. And the landlord was angry. He didn't want the children in his house. So Ghartay found them another place to live. But that land-lord also canceled the deal upon learning they were Ebola survivors, said the pastor.
He finally found them a two-room place on the edge of the village. But they have not been embraced by the community, said Hawa Kaifa, who, at 21, is now the family caregiver.
"Yes, I feel like a true outcast, I have nobody," she said. "I had a best friend at school be-fore Ebola. And since I came from the Ebola unit, she never talked to me. She never visited me. Then I called her one time and explained to her that I'm a survivor of Ebola. I no longer carry the virus. She came to me once, but since then I have not seen her anymore."
Kaifa now cares for five children, including two of her own and three siblings ranging in age from 2 to 15. During Monday's ceremony, President Johnson-Sirleaf made a point of high-lighting the Kaifas. She called them to the front of the church to recognize their survival and to laud the community's support.
"We are going to work with you and with the church to see what we can do," Johnson-Sirleaf told them. But in an interview, Kaifa started to cry when asked if she was honored that her story helped draw Liberia's president to her village.
"I feel proud that she's coming to this community because of me," she said. "But it's just sad that she's coming because my whole family died."
II FFEEEELL OOKK AANNDDEERRSS KKEELLTTOO DDEECC 99
As part of Sierra Leone's broader effort to contain the deadly Ebola virus, the country opened a new ambulance dispatch center in September in the capital, Freetown. Along with a new Ebola hotline, the center is considered an important step forward in the war on Ebola. But on the center's second day of operation, a series of errors put the life of an apparently healthy 14-year-old boy at risk.
The dispatch center is situated in a meeting room at the Cline Town hospital just north of downtown Freetown. Inside the room, a group of men and women are huddled around a table full of laptops. Safa Koruma, a technician, points at a message on a screen. It describes a possible Ebola patient, reported through the hotline, with the words "vomiting and very pale."
Koruma forwards this message -- along with hundreds of others -- to the nearest health of-ficial. A community health worker is then supposed to evaluate the patient and assess the likeli-hood of Ebola. "Probable" Ebola cases end up on a large whiteboard on the other side of the meeting room. It's the master list for ambulance pickups. Victoria Parkinson, of the Tony Blair African Governance Initiative, is one of the directors of the center. She points at a name on the board with the number five written next to it, indicating the number of cohabiting family mem-bers.
"We want to get that [person] quickly, because there's many people in the home that could be infected by," she says. One of Parkinson's colleagues, Ama Deepkabos, writes down an address and hands it to an ambulance driver. "It's 7 Hannah Street, 555 Junction. Do you under-stand?" she says, imitating the local Krio accent. "Go directly to the patient. No other stops!"
The driver nods and hustles out to the dirt parking lot, along with a nurse. I attempt to speak with the driver and nurse, but neither speaks good English. They step into a white Toyota SUV with the word "Ambulance" in large red letters, and pull out of the parking lot. Sierra Leone is in the midst of a three-day national lockdown, intended to slow the spread of Ebola, so the roads are clear. The ambulance speeds across town and is waved through multiple police check-points.
After two wrong turns and several stops for directions, it eventually bounces down a long dirt road in Waterloo, a rural suburb 15 miles southeast of Freetown. The driver and nurse spot the person they believe to be the patient: a 14-year-old boy in a blue T-shirt slouched on a white lawn chair. They get out and put on glimmering white protective suits, surgical masks and rubber gloves. They walk over and escort the boy, who is able to walk on his own, into the back of the ambulance without touching him. They kick the door closed behind him.
The boy's guardian, Suleiman Espangura, is the principal of a nearby high school. He re-cently took the boy, Ngaima, into his custody because his family was moving to a rural part of Sierra Leone, and Ngaima wanted to stay at his current high school near Freetown. "He likes to play football," Espangura says of the boy. "And he's very clever. We [teachers] like children who are clever."
Espangura says he's unclear why Ngaima is being taken away in an Ebola ambulance. He says the boy doesn't have any signs of Ebola -- no fever, no vomiting, no diarrhea. He just has a headache and a slight loss of appetite. But because Espangura had heard multiple public service announcements encouraging people to report any signs of illness, he contacted a health official and was told a community health worker would come to evaluate Ngaima. Instead, an Ebola am-
bulance showed up.
Espangura says the ambulance driver and nurse asked him if Ngaima was "the patient." Espangura said yes, thinking the men were here to evaluate him. Instead, they ushered the boy into the ambulance and whisked him away. The ambulance rushes across town to a military hos-pital with an Ebola isolation unit set up outside -- a series of white plastic tents with a blue tarp stretched around the perimeter. The hospital guards, in military fatigues, tell the ambulance driv-er and nurse that Ngaima is not on their list of expected patients. A heated argument ensues. The driver insists that he is merely following instructions, and that this is the correct patient.
One of the guards eventually calls the head of the hospital, who consents to admitting Ngaima. The driver and nurse spray the back of the ambulance with chlorine and open the door to let him out. Ngaima steps out of the vehicle and disappears behind the blue tarp fence, into the Ebola ward.
A few minutes later, another Ebola ambulance arrives. The military guards are expecting this patient. But they say the beds are now completely full -- Ngaima has taken the last one. The new patient is admitted anyway. It's not clear exactly what went wrong here. But now, a 14-year-old boy with a headache is sitting inside an Ebola isolation center.
RREEPPOORRTTEERR''SS NNOOTTEE::
Peter Breslow, my producer, and I didn't realize what had happened until the following day, when we were reviewing recordings of the event. We noticed that the names given to the ambulance driver did not match the names of Ngaima or his guardian, Suleiman Espangura. We immediately contacted the ambulance dispatch center and Espangura to explain what we thought had happened. The ambulance dispatch center neither confirmed nor denied having made an er-ror.
Ngaima was kept at the isolation unit for the next six days, despite being told that he would get his Ebola test results within 24 hours. Ngaima eventually tested negative for Ebola and was discharged. But it was possible that, between the time his blood was taken and the time he was discharged, he could have been infected by another patient.
EECCOONNOOMMIICC IIMMPPAACCTT DDEECC 1100
They're from the same ethnic group. They speak the same language. And they live on both sides of the Liberia-Guinea divide in the area around Liberia's eastern border city of Ganta, in Nimba County. The families straddle the border, which is not fenced.
"Right over there is the border," says businessman Prince Haward, directing our attention to some rubber farms not too far away. "Those are the rubber farms you find in Guinea."
Many families have relatives who live right across St. John's River, which separates the two countries, he says. They used to cross back and forth at the busy border post. Then Ebola came, arriving in Liberia back in March when someone from Guinea entered the country. To curb the further spread of the virus, Liberian officials shut the border in July.
Haward, whose family has lived in the area for nearly a century, calls the government wise for closing the border to help protect Liberia -- and Ganta. "Life comes first," he says, "be-fore economic activities." There has definitely been an economic impact.
Kono District is a land of towering mountains and muddy diamond mines. It's right next to the region where the Ebola outbreak first started. Still, for a long time, it looked as if the virus was mostly bypassing the place.
Over the summer, there were just a handful of cases, says Winnie Romeril, the World Health Organization's spokeswoman in Sierra Leone. There were a few cases a week in Septem-ber and October. "And then suddenly in November we noticed a rise in the number of cases," Romeril says.
The actual figures were still fairly low: a few dozen sick people at the district's only hospi-tal. To date the total number of confirmed cases in Kono is just over 120. But the suddenness of the rise was ominous.
"We were analyzing these figures and scratching our heads and thinking well, we need to go see what's going on," she says.
Romeril was in a group of aid workers and government and international organization of-ficials that arrived last Saturday. Their first stop was the hospital. They found it overwhelmed with desperately sick people. Dead bodies were piling up. As for the nurses: "You could see the toll that was taken on the staff. I mean they were, they were some of the most exhausted, de-pressed looking people I've ever seen," says Romeril.
The only good news was that the staff had enough protective suits, provided by the gov-ernment in advance. Everything else was lacking -- even cups. That's a serious problem because Ebola patients lose a lot of fluid. The key to survival is to drink large quantities of a solution of water mixed with oral re-hydration salts -- called ORS for short.
"People who are so weak with the Ebola virus can't even pick up a one-liter bottle," Romeril says. "So you have to put it in a small cup for them to sip out of. And they didn't have small cups. They didn't even have pitchers to make up the ORS."
The staff also hadn't been trained on how to set up isolation zones. "So they were actually carrying people who had died of Ebola to the morgue and passing the pregnancy ward, for ex-ample," she says. "And by the time we left there were already pregnant women dying."
Also among the dead: hospital workers. And it was likely that there were a lot more in-fected people in the community. But it was hard to say for sure. Michael N'Dolie is an expert on disease surveillance with the World Health Organization. When he arrived in Kono -- just a few days before Romeril -- he found that the teams who check reports of suspected Ebola patients had no cars or trucks.
"They only have motorbikes," he says. "In fact as I'm talking to you, it's still a challenge. We still do not have one vehicle for them."
Even when the team members do manage to reach homes of sick people, they can't then take the individual to the hospital on a motorbike. So they lose precious days trying to organize ambulance rides. But what about all the money the international community has been pouring into Sierra Leone? How is it possible that there still aren't enough vehicles, or cups? One reason, says Romeril, is that the hot spots keep shifting from one part of the country to another.
"The resources have been diverted to areas that seemed much more needy at the moment, and then another area gets neglected," she explains. "And so even when a lot of resources have come in there are still more resources that are needed."
Kono, at least, is getting help. The World Health Organization and the government of Si-erra Leone are now teaming up with non-governmental aid groups to mobilize a rapid response. They're sending vehicles. The International Federation of the Red Cross is setting up a proper treatment center that should open within two weeks. So Romeril says there's reason to hope they can stamp out this particular brush fire. Still, she says, the episode is one more reminder of the need for constant vigilance.
PERSONAL NOTES FROM WEST AFRICA, OCTOBER 2014
My sojourn in Liberia in the fall of 2014 left me with experiences I've found extraordi-narily difficult to articulate. It's not just that writing isn't my primary skill. Liberia, in Ebola time, took me out of my comfort zone, which is actually larger than the planet earth. The journey was totally worthwhile for myself but my deepest impressions, the deepest thoughts, fall into the world of feelings, into a remote region in Richard, and although I would like to share them, I've been unable to precipitate them into words on paper.
Despite this, a personal journal is an acceptable place for recording trivial events and cir-cumstances. I seem to have a particular skill in recognizing trivialities. Trivial observations fall across a spectrum and if you go to the far right, past the point where the wavelengths are measureable, trivialities sometimes seque into the spectrum of things worth noting.
Liberia is filled with young men and women and truckloads of real little kids who are even more lively, curious, playful and entertaining as are the kids at home. They skate about, playing on the surface of a thin sheet of ice which cverlies a deep lake of hunger and fear. After awile in the country, the thin sheet of ice seems to fade out of sight, and life becomes an in your face balancing act, playing on the edge of catastrophe.
Whatever the reasons for this, there's no excuse for the world to ignore such a situation, for not ensuring that at least a minimum foundation is put in place for our fellow man.
I suspect one reason why I've included such an eclectic collection of reports in this chapter is because the onsite media are doing such an excellent job in documenting various aspects of the Ebola epidemic and it's impacts on west African residents. They put into words much of what I've had difficulty saying.
My expressive aphasia appeared shortly after arriving in Liberia. In an early email to my kids, I wrote: "Just because I don't write about a lot of sad things doesn't mean they aren't an everyday, in your face, part of life here. Your heart begins to ache for the people and right now, hee, there's nothing in place or in sight, that can make it better."
To a large degree, the reporters, photographers, the health workers who've come to west Africa in response to the Ebola epidemic represent the largest concentration of well intentioned people ever gathered together on earth. To a virtual certainty, no outsiders are here for the mon-ey. If I had the money I'd collect a thousand blood samples from them for genome sequencing. Perhaps there's such a thing as a do-gooder gene. A good thing to do would be to discover it, for the benefits of all mankind, of course.
In this last segment of Chapter 7, I'll write of some of my experiences in Liberia. On the surface, my trip was a search for answers to some major questions about how this epidemic got loose and what steps the world must take to prevent such a thing from ever recurring. Legitimate questions though usually the objects of inspection by large organizations, committees and groups of specialists.
My experience in Liberia, along with an in depth review of the scientific literature [and media reports] on Ebola [and this epidemic], provided me with evidence based answers to those questions. From this perspective, the journey was worthwhile. On the other hand, the experience of a world teetering on the brink of an abyss, filled me with a long lasting dis-ease.
On the night I left Liberia for home, when the Boeing 737 tucked it's gear up into it's me-tallic body and climbed northbound into the tropical night, I felt as if I were being winched up-wards to the safety of a world light and security, exiting from the depths of a dark well.
I felt sad to be leaving, sad not to have all the answers for what I'd observed and strangely guilty, perhaps for having been born into a land which provided all the basic elements for a nor-mal life. All the elements of our daily live that are so common and taken for granted, they don't even cross our minds over the years.
I was leaving behind many new friends, younger men and women, who lived lives of qui-et desperation, angry at the lack of opportunity, the absence of the kind of hope that we at home take for granted. Hundreds of thousands of human beings eager to work, to advance, to give their families a basic standard of living, to be free of bribe demanding cops and corrupt politicians... they remained behind to continue their elemental struggle, living on a level that most of my countrymen could scarcely imagine, and that's without Ebola.
If you conclude from these morose words that I'm an ongoing bundle of sadness and guilt however, no, it's not true. I know enough of life to know it's a waste time to grind around in the turbulence of unsolveable philosophical and economic dilemmas. Someday I'll figure it all out, and then I'll do it right. Until then, my modus operandi is to isolate my enthusiasms from all the unsolvable condundra of life, which seem to survive nicely locked away in a secured mental compartment,
But if I were King of the Universe, heads would roll.
QQUUEESSTTIIOONNSS
Previously in this chapter I've described the questions about this Ebola epidemic, that had triggered my decision to go to Liberia. Watching the Congressional Hearings on Ebola in the lat-ter part of September strengthened my desire to go. The questions I had were substantial, ques-tions more suited for an attack by large groups of researchers, but I knew that. I wasn't under any illusions as to what I might accomplish in clarifying the bigger picture.
The RRF concept [drbargen.com] and it's applicability to this mandemic, was on my mind. I felt confident in my ability to observe, to evaluate and to reach valid conclusions in dis-aster-like circumstances. Keeping an open mind is difficult, but improves with practice. I felt confident that I could maintain an open, though non-gaping, mind.
I felt confident in my ability to get close to the 'enemy' and assess his strengths and weak-nesses. I hoped to get access to real world primary data which would allow me to follow my nose to the answers to the key questions: why was this epidemic so different, so much worse, than any
previous Ebola outbreak and what steps need to be taken to prevent such an outbreak from ever happening again?
If I didn't discover acceptable answers to my questions, I would still be able to: work with some of the many global experts that I knew were already in the field searching for answers to very similar questions; to join with medical volunteers in the field, professionals who were doing their best to detect, isolate and treat the current Ebola victims along with tracing their contacts.
1. I didn't want to work with any NGOs, especially those who might accept me. The treatment and care of Ebola victims obviously was one of the major needs in west Africa, but it was only one of a number of major needs to which one could lend a hand. My experience with NGOs is that they ... Sometimes it's better to leave things unsaid.
2. Prior to departure, I already had suspicions that current Ebola epidemic had erupted as it had, due to failures in medical intelligence, governmental missteps, and so on. West Africa in 2014 was not simply a nasty virus running amok.
If this suspicioun correctly identifies a major factor which facilitated the spread of this ep-idemic, then it will continue to exist and aggravate potential disasters in the future, unless we study it, and replace it with plans for effective action..
3. At no time prior to, or during my journey, did I have any concerns about my personal safety related to the epidemic. Presuming that the most qualified people to work in Ebola epi-demics, are those who are the most expendable, I qualified beautifully. Nobody at home any longer depended on me for their survival. I have a utilitarian value in a Darwinian sense, but that's not a factor in this equation.
My physical safety was 95% dependent on the exercise of my professional knowledge of the disease, with a 5% risk due to unknown, unpredictable, stupid things in life.I thought of tak-iing a PPE course at CDC before departing, but decided that if I ended up working with Ebola infected people, I'd learn the proper PPE techniques from those in the field, those who had actual experience with Ebola, and who proved, by the fact that they were alive, that they were experts in the field.
The truth is that during my journey to and time in, west Africa, my safety was at greater risk from car accidents or from my cooking, than from Ebola virus.
PPRREEPPAARRAATTIIOONNSS
Usually I can depart on a journey for most places for a few months, with just a few hours of preparation. This September, thanks to my physio-expert daughter Nicole, it only took me one day to get in shape.
The second day of my preparation was devoted to getting all my shots and then, not being content with that ordeal, going to the dentist to have five teeth pulled -- the really big teeth to-wards the rear, each with roots than extend back to the old country. If I'd stayed, the dentist would have drilled and filled them. But I wanted to leave yessterday, and I needed to be free of dental concerns for at least six months. The only option was to terminate the molars with ex-treme prejudice.
The second day of preparing for west Africa, thus was a lesson learning day. The key les-son of life that I learned getting all your shots in the morning, topped by a five dental extraction chaser in the afternoon will [like the Mamas and the Papas sing] take you where you've never been before. Although the trip is free, there are no airmiles, and you are lucky if a return ticket appears.
I wanted something to take my mind off the pain and suffering generated by the five hun-dred bucks I put out for shots, and the 1600 bucks for my demolarization, and the actual experi-ence filled the bill.
Finally, my financial assets were miniscule, so I took them all and purchased a one way ticket to Monrovia, Liberia. It felt like money well spent, but how would I know.
NNYYCC
A newbie in New York accumulates experiences at a rate that can trigger a B Bus over-load. Things happened to me personally or to others around me, faster than I could record them in my journal. That probably explains the number of people I passed on the sidewalk, walking along with their video phones held up, doing a self-walk in the city.
Everyone else was talking on mobile phones, some with tiny ear pieces that allowed them to walk along seemingly talking to themselves, looking like a nation of schizophrenics.
I'll share one NYC item from my journal and then spare you the rest. On the second morn-ing in NYC, I awoke to a slightly rainy, dreary looking day. I had errands to do. As I walked east along 8th Avenue, I tried out my newly purchased umbrella [I've never seen an umbrella in Ne-vada, ever].
There was a button in the handle and when it was depressed, the entire umbrella sprang out in a tenth of a second, unfurling like a spacestation solar panel. The areal extend of the um-brella was such that if I needed some space to myself on the sidewalk, I could hold the umbrella at head level, depress the ignition button, and the umbrella would burst open clearing pedestrians from about 12 square feet of sidewalk. Handy...
Walking along in the early morning rain, I became aware of a young man on my left who was keeping pace with me. When I looked to my left, I saw that my companion was a trim black dude about twenty years old. He was wearing fashionable shoes but other than that, I couldn't see much of him.
For rain protection he was wearing a large dark, green garbage bag of his own design. Through an 8 inch hole torn into the top of the garbage bag, a large bolus of his dark hair pro-truded in a big coil. I got the impression of a being accompanied by Angkor Wat.
He navigated normally, peering through two eyeholes torn into the front of the garbage bag. There was no mouth opening or nose hole. A small hole torn out of each side of the garbage bag, allowed his arms to stick out. The plastic bag extended down to his knees.
The garbage bag man and I had walked together in light rain for just a couple of blocks another pedestrian closed on us from the rear and passed by. I glanced at him as he passed. He was also a young black guy, dressed relatively well. He had a slightly strange look on his face. When he got about ten feet ahead of us, he stopped abruptly in the middle of the sidewalk. He bent over at the waist and began dry heaving loudly, his entire body shaking from the effort.
My mind still grinding through a medical differential diagnosis list, when the dude straightened up, and began walking again. As he walked, his head was thrown back and he laughed loudly, hysterically and continuously. Fifty feet along, the man abruptly halted again, bent over and began the same routine. After fifteen seconds of wretching, he once again straight-ened up and continued walking along 8th Avenue, laughing uproariously.
After finishing his dry heave routine the third time, he walked across an intersecting street crossing, all the while laughing his head off. The light changed just as the man in the garbage bag and I reached the curb. We stopped and stood side by side, watching the performance going on across the street.
For some reason I briefly glanced to my left. When I did, I caught the man in the garbage bag looking right back at me. I was staring right into his little green face. His eyes peered out of the two little holes in his bag, and for a brief moment, our eyes locked..
Before I could even take a deep breath, I heard his voice, his words slightly muffled by the acoustics of his garbage bag, "Man, this city is really gettin weird."
We both burst out laughing. Although I'd just arrived in NYC and hadn't had enough time to form a solid opinion on the matter, I suspect he was right.
CCAASSAABBLLAANNCCAA
[This segment is a bit of silliness which may feel out of place when writing about a deadly epidemic. I include for myself, just because ...]
Casablanca, the setting of my favorite movie. I'd waited a whole lifetime for a chance to visit Casablanca. Now, even if only for a few hours, I'd be in Casablanca, Perhaps someone -- the Customs Officer --- might ask me what I was doing here.
Officer: "What in heaven's name brought you to Casablanca?" Me: "My health. I came to Casablanca for the waters." Officer: "The waters? What waters? We're in the desert." Me: "I was misinformed. So I'm going on to Monrovia."
Morocco looked gorgeous from the air and I'd love to go back someday and tour this country. I remained on alert during my entire stayover at the air terminal, eager to quote a few lines from the movie, but during those 18 hours I never encountered a single person or situation
WWHHEEEELLSS DDOOWWNN IINN LLIIBBEERRIIAA
When I arrive in a new country, usually seeking out a disastrous circumstance, unconnect-ed with any groups or organizations, it takes me a few days to get the lay of the land and orient myself appropriately with respect to my goals.
I've learned that hooking up with a local person who is personable, knowledgeable about people, language, customs, and trustworthy, and punctual, this is a valuable, time saving, and risk lowering hookup. Where does one find such a creature? It happens....
1. Ominous sense of the country: basic life, dark, curfew, shadows. Mind working over-time.
2. Need to get oriented, find the key players and hookup to pursue specific goals: access data, get the most accurate story available and determine known factors related to the anomalies of this epidemic. Assuming there were exacerbating factors, not that the Ebola virus had mutated perhaps and now was just a nastier actor.
3. Oriented to task quickly but not to directions. Through good fortune, met James Akura at the airport on arrival. He became my man Friday and was invaluable in helping me navigate the terrain and pursue my goals.
His father had been a physician also. James was 24 years old. When he was 14 his father, at work in a Monrovia hospital, was killed by rebels in the civil war that was savaging Liberia.
DDAATTAA
During the first week I located the major players in the Ebola response effort, located the places with the most accurate data related to the epidemic. This latter is a relative term, "accu-rate." The data related to Ebola, the number of victims, their locations, their 411, the number of deaths, and so on, was poor quality, if not being out rightly deceptive and worse than useless. But it got better with time.
Locating the key players in the Ebola response organizations.
JJAAMMEESS AAKKUURRAA
My good fortune was to meet James Akura at the airport when I arrived in Monrovia on a hot, dark night. I ended up taking his car for the 50 minute drive into Monrovia. I quickly learned that James, 24 years old, was a sharp, street wise, honest and punctual man and he became my man Friday in Liberia.
Completely the opposite of the stern visage James presented to the photographer, he was jovial, liked jokes, and had a remarkable attitude about life in a marginally livable land.
A good man Friday is essential to low risk business dealings and efficient movement through a new culture.
The regular population in Monrovia communicates in a form of English which I couldn’t understand. When speaking to outsiders like myself, a Liberian speak regular English, often ar-ticulate and quite understandable.
James was extremely helpful in facilitating communications with folks on the street or in regular businesses. He’d often conduct an entire transaction himself in Liberian English, know-ing what I needed. Or he’d translate what a Liberian was saying to me. However it went down, his service speeded everything up by an order of magnitude.
OOTTHHEERR
Would like to see outside investments in Liberia. The opportunities to build businesses with eager hard working Liberians exists.
Becoming familiar with the situation, the response: learning from the IMS meetings, learning that the epidemic is due to extrinsic factors such as the nearly nonexistent health care systems, superstitious people, corruption, wars, travel, refugees, and so on. But the virus has not changed significantly. This means we have a chance to implement surveillance and alerting measures, constitute rapid response teams benefiting from local Ebola testing, trained medical personnel, and existing facilities, to bring any future Ebola outbreak to a rapid halt before so
there would never be more than ten or twenty victims.
ABOVE: James and his family.
Honor those medical personnel who gave their full measure in the fight against Ebola, in the early period of the epidemic when their efforts with inadequate resources, delayed the spread sufficiently to buy time for the follow on efforts as the world slowly awoke to the existence of this deadly threat. All their names should be documented, and their sacrifices acknowledged. The medical personnel who fought Ebola constitute a noble and heroic chapter in the annals of medi-cine.
Luckily walked into these meetings, the equivalent of the presidents Ebola task force. Met key players, got solid, timely information, and began to clarify my understandings of how this epidemic begin, why it spread as it had, where it was likely going and what we needed to do, programs or systems that needed to be implemented in order to prevent Ebola 5.0 from ever see-ing the light of day.
SSIIRREENNSS
On the journey to Liberia I'd spent a few days in New York, obtaining a few necessary supplies. Hostelled near 31st Street and 8th Avenue, the night often resounded with the wails of sirens, ambulances, fire trucks. The contrast with a night in Reno was marked.
Monrovia, however, outdid New York City in this regard. Ambulances in Monrovia were used to transport new Ebola victims, along with bodies of those Ebola victims who'd expired. They worked primarily during the daytime, as the curfew was in effect. Each day of the first two weeks I was in Monrovia, the city environment resounded with the wail of sirens, the sounds of Ebola ravaging the city. The cacophony exceeded by far that in New York. Most residents seemed accommodated to the ominous sounds, but I'd never heard anything like this anywhere
ever.
Especially dissonant was the experience of watching a group of kids playing in a field, yelling and shouting happily, while their cries were overlain by the wavering sirens of passing ambulances bearing the dead and dying to places that likely would be their final resting place.
The kids seemed oblivious to the cauldron of fear and death in which their games were embedded. I was familiar with this phenomenon from Sumatra in 2004. The experience still trig-gered the powerful sensation that I was somehow viewing life through a cracked mirror. The media report below focuses on Mr. Gordon Kamara, one of Monrovia's ambulance drivers.
Racing along cracked and bumpy roads here, Gordon Kamara shouted into his cellphone over the shrieking sirens of his ambulance. The phone had been ringing nonstop since 5 a.m.
"Not today! Not today!" Mr. Kamara, an ambulance nurse, yelled later in the day. "We are on the opposite side of town!"
The calls have all been the same in recent weeks: from friends, friends of friends, extend-ed family, complete strangers. All of them have loved ones sick with Ebola and beg him to come quickly. Seven days a week, Mr. Kamara and his crew span Monrovia, Liberia's capital, in a do-nated, old American ambulance -- with California license plates still attached.
"It never stops," said Mr. Kamara, getting another call the moment he hangs up. The 15 or so ambulance teams bolting around the city have had many days of hard choices like this. Hun-dreds of new Ebola cases are reported each week in Monrovia, with many more never accounted for. And over the course of the epidemic, only a small percentage of them have ever made it to a hospital.
"We see it flow through the communities; first one, then many," Mr. Kamara said. "The map is being painted red with the virus."
To confront the spread of Ebola, some community groups have stepped in, motivated by altruism, desperation and, in some cases, political opportunism. In some neighborhoods, teams of volunteers fan out to track victims and educate households on staving off the virus, though their pockets are so shallow that they often do not have enough supplies, like chlorine, to thwart the epidemic's advance.
Mr. Kamara does not work for the government. He does not even have a dispatcher to tell him where to go, or which patients to pick up. Instead, his team is financed by an opposition member of Parliament, Saah H. Joseph, who imported two used American ambulances to Mon-rovia this year. Mr. Joseph claims to bankroll the operation on his meager government salary, and he deployed the ambulances even before Ebola overran this city. It was a way of shoring up Monrovia's tattered health system -- and of making a name for himself.
But many here wonder whether other political opponents of President Ellen Johnson Sir-leaf are the real money behind Mr. Joseph's ambulance squads, hoping to use them as a form of public shaming of the government. There is little question that the city has long suffered a major ambulance shortage. And since the epidemic struck, other independent ambulance teams have sprung up, adding a few more vehicles to what is still a tiny fleet in this sprawling city of nearly 1.5 million people.
At the end of a recent 15-hour shift, Mr. Kamara took his final patient of the night, a 17-year-old girl, to an Ebola treatment center. Wrought with fever, she had stripped off her clothes in the back of the ambulance and fallen off the stretcher, lying twisted and barely conscious on the floor. "If she does not get treatment, she will die," Mr. Kamara said.
But as soon as they arrived, he and his team were turned away. All the beds were full. The center, meant to house 50 patients, was packed with 85. "We could either leave her on the ground to die, or return her to die at home," Mr. Kamara said. "There's no hope here. We try our best. But we cannot do more than we can do."
In recent days, the flow of patients, somewhat inexplicably, seems to have slowed, and beds are suddenly available in some places. Many people wonder if it is a reflection of interna-tional efforts to add treatment slots, or a sign that some clinics are seen as deathtraps from which sick relatives will never return, leaving many patients to opt for taking their chances at home in-stead.
But the current ebb is a rare -- and not entirely trusted -- respite from the typical frenzy.
Most days, Mr. Kamara and his team work from sunrise to long past sunset, often sleeping in the ambulance for rest. On a slow day, he has ferried 10 to 15 new patients from their homes to Ebo-la treatment centers. On a busy day, the number has been between 20 and 30.
"When there are beds at the centers, we can do our work," Mr. Kamara said. "When there aren't, we must sit and wait," he added, explaining that his ambulance would sometimes wait outside a hospital for hours, with a patient in the back, until a treatment slot opened up.
Mr. Kamara is no stranger to suffering. More than a decade ago, he worked as a combat medic during Liberia's civil war. "It is nothing compared to this," he said. "The bullets you can get away from. Ebola is hidden within our own families."
Last month, he received news of an uncle falling ill. He rushed to the hospital to help, on-ly to be turned away by workers there. "Nobody knows who is alive or who is dead in here!" Mr. Kamara shouted. "I would go treat him myself if they let me. I just want to protect my family."
He takes many precautions at home. With his constant exposure to the virus, he sleeps in a separate house from his six children to prevent them from getting sick. In the past five months, he has seen them only a few times.
"It's a very lonely virus," Mr. Kamara said. "Not just for me, but for the entire country. We are all together, but all alone." As he returned the 17-year-old girl to her home, Mr. Kamara ex-plained to her brother why they had brought her back.
"We didn't want to leave her outside and alone," he said. "We will come back to pick her up tomorrow in the morning and try again."
Her brother calmly accepted the news. He thanked the ambulance crew for trying, and opened the door as they carried her limp body inside the house. She died the next morning, be-fore the ambulance team could return.
HHAAWWAA KKOONNNNEEHH
My friend Richard Misrach, a photographer with a global reputation, was looking over some of my photographs during a visit to Nevada. After a few minutes of silence, as he sucked in the powerful aura of the images I'd selected for him, he looked up and said "Stick to medicine, Richard."
My dreams of becoming Eliot Porter the Second burst into flames and fell to the floor at his feet. But even though I may not take memorable photographs, I do recognize photographs that have that special quality, images that are iconic and will be memorialized amongst the world's unforgettable images.
The moment I saw Daniel Berehulak's photograph below, I knew this was one of those ra-re images that belonged in the archive of historic images. Daniel Berehulak of the New York Times took the photograph in Liberia where he documented various aspects of the epidemic with grace, dedication and courage.
This image records workers with Doctors Without Borders disinfecting a bag containing a blood sample obtained from the nearly shapeless bundle of material lying in the dirt at their feet. That bundle is actually a 9 year old girl named Hawa Konneh. She has Ebola and she would be dead in less than an hour. The shocked woman to the left is Hawa's mother Masogbe.
This powerful image encapsulates the pathos and tragedy of the Ebola epidemic. Profes-sional skills as a photographer only prepare the substrate for the creation of such an iconic im-age. More than anything, capturing this image required courage and a powerful belief in the im-portance of documenting the epidemic induced disasters..
After viewing this image, discussing it with my kids, we adopted it amongst ourselves, as the visual depiction of everything involved in our journey to west Africa. Nine year old Hawa Konneh, a citizen of Liberia, through Daniel Berehulak's unforgettable photograph, became the human face of our somewhat technical project. When my daughters were nine years old... it's just a short mental journey down that road to the inexplicable paradoxes of life.
Earlier in this chapter I described a remarkable photo by Daniel Berchulah, taken in the MSF ETU in Monrovia. A 9 year old girl, Hawa Konneh, lies on the ground, almost indistin-guishable from a pile of discarded rags. She’s dying of EVD. Her distraught mother sits at a dis-tance, two MSF workers doing what they can in a hopeless situation. The image captures the pa-thos of the Ebola epidemic, the cruel shattering of everyday human bonds, and the massive ineq-uities that life visits on humans.
Daniel Berehulak's photograph of little Hawa Konneh
Courage is required to take such a photo, to overcome the natural reluctance to intrude on a tragic event. The photographer documents one brief moment out of thousands of such moments that this epidemic has generated, most of which occur unrecorded, unnoticed by the rest of the world. I could only think of my girls when they were nine. I discussed this photo with my crew back home. We decided to “adopt” Hawa Konneh, as an act of respect for the little girl we never knew, as well as for all the lives cut short by this epidemic. It became our private icon symboliz-ing this terrible epidemic. Clearly, this is difficult to put into words.
Daniel’s photograph, for ourselves certainly, is a member of that small collection of imag-es that are recognized globally as unique depictions of profoundly moving events. My journey to Liberia would not be able to “make it better” for Hawa, or for anyone else really. But I hoped to help ensure this never happened again, anywhere.
Accessing the best data, though it wasn't that great. This part of project never progressed. The Swedish epidemiologist at IMS.
Things coming together, understanding why the epidemic had spread so widely, spread out for control, wasn't alerted until six months or more.
Failure of medical intelligence, established alert systems, Due to factors on the ground and incompetence of WHO, inattention of other countries.
The fragile nature of social structure armed drunk cops shaking people down. Anything bad can happen at any time.
BBIINNGGOO SSCCOORREE I’d worked with my friend Steven Rothman not that long ago, helping to refine his re-
markable algorithm, the Rothman Index. A large number of weighted parameters derived from a patient’s health record, are tossed into the algorithm box which generates a number between 0 and 100, the Rothman Index. which roughly correlates with your probability of living to see the sun rise next day. 100 is great, 1 is dead.
We discovered that data normally not incorporated in determining the patient’s score [such as their vital signs, lab values, etc] could also be used to refine the algorithm’s accuracy. One of the most powerful predictors of a nursing home decline in health, was their attendance at the frequent bingo games usual endemic to nursing homes.
If a resident has begun to have serious problems with his health, a week or more prior to this situation being disclosed to medical staff through his complaints, changes in his vital signs, and so on, he will stop attending the nightly Bingo games held in the nursing home. Properly weighted and incorporated into the RI algorithm, the Bingo score enhanced RI can give staff a headsup about a serious problem that would normally not become apparent for another week or
Daniel Berehulak's photograph of little Hawa Konneh
Courage is required to take such a photo, to overcome the natural reluctance to intrude on a tragic event. The photographer documents one brief moment out of thousands of such moments that this epidemic has generated, most of which occur unrecorded, unnoticed by the rest of the world. I could only think of my girls when they were nine. I discussed this photo with my crew back home. We decided to “adopt” Hawa Konneh, as an act of respect for the little girl we never knew, as well as for all the lives cut short by this epidemic. It became our private icon symboliz-ing this terrible epidemic. Clearly, this is difficult to put into words.
Daniel’s photograph, for ourselves certainly, is a member of that small collection of imag-es that are recognized globally as unique depictions of profoundly moving events. My journey to Liberia would not be able to “make it better” for Hawa, or for anyone else really. But I hoped to help ensure this never happened again, anywhere.
Accessing the best data, though it wasn't that great. This part of project never progressed. The Swedish epidemiologist at IMS.
Things coming together, understanding why the epidemic had spread so widely, spread out for control, wasn't alerted until six months or more.
Failure of medical intelligence, established alert systems, Due to factors on the ground and incompetence of WHO, inattention of other countries.
The fragile nature of social structure armed drunk cops shaking people down. Anything bad can happen at any time.
BBIINNGGOO SSCCOORREE I’d worked with my friend Steven Rothman not that long ago, helping to refine his re-
markable algorithm, the Rothman Index. A large number of weighted parameters derived from a patient’s health record, are tossed into the algorithm box which generates a number between 0 and 100, the Rothman Index. which roughly correlates with your probability of living to see the sun rise next day. 100 is great, 1 is dead.
We discovered that data normally not incorporated in determining the patient’s score [such as their vital signs, lab values, etc] could also be used to refine the algorithm’s accuracy. One of the most powerful predictors of a nursing home decline in health, was their attendance at the frequent bingo games usual endemic to nursing homes.
If a resident has begun to have serious problems with his health, a week or more prior to this situation being disclosed to medical staff through his complaints, changes in his vital signs, and so on, he will stop attending the nightly Bingo games held in the nursing home. Properly weighted and incorporated into the RI algorithm, the Bingo score enhanced RI can give staff a headsup about a serious problem that would normally not become apparent for another week or
more.
Today, we don’t have the ability to predict an Ebola outbreak. The historic Ebola out-breaks have been tied in a general way, to such factors as the ever increasing intrusion of humans into previously inaccessible jungles and the increasing population in central Africa eating bush-meats. But no known factors allow the prediction of an Ebola outbreak two weeks hence.
Developing the capability to predict such an event isn’t farfetched. There could be a bingo score residing in central Africa just waiting to be discovered. For example, we learn that every Ebola outbreak has been preceded by a week of unusually heavy rainfall in the region where the outbreak will occur. It doesn’t matter why this is so, but if it is so, this correlation needs to be incorporated into the Ebola surveillance systems.
Perhaps it is a fact that there has never been just one isolated case of EVD. In every in-stance where the diagnosis of EVD has been made, in just one person, there has followed an out-break of Ebola with tens to hundreds of victims. If this is the case, then by ramping up the ability of a rural clinic to accurately and swiftly test for Ebola, will reward us with early detection of that first case. The detection of one case will trigger the deployment of a 200 person Ebola re-sponse team. The team will be onsite in less than 24 hours and initiate an intense search for other Ebola infected persons and will do some rapid, in depth contact tracing.
Scenarios such as the above should ensure that Ebola never again runs free as it has in west Africa. In any case, unlikely as it would be to discover such bingo score factors, Ebola out-break correlations as yet unrecognized, it wouldn’t hurt to keep one’s mind open to the possibil-ity. Also, the anomalous nature of the current epidemic remains unexplained. There may be other elements in the environment which, when present, predict that an Ebola outbreak will outrun ef-forts to contain it. As long as so much about Ebola outbreaks remains a mystery, a continuing a search for predictive correlations is a rationale activity.
I’ve been in Monrovia three days now. James drove me out to the MSF ETU situated on the airport road in Monrovia. MSF is currently expanding it’s capacity for treating EVD. The ETU is structured like a military fort, with different zones, each with different functions and se-curity requirements. At the core of the establishment is the active treatment unit. This is the highest risk zone.
The basics of the MSF operation were explained to me by a couple of nurses who were off shift when I arrived. Their courtesty was appreciated. Knowing what these women did every day in treating EVD, created an almost palpable aura of respect and admiration for them and their many teammates. MSF, almost alone, has carried the ball when the rest of the world inexplicably focused on other things. They more than deserve the respect and honor given them by those who know, and thankfully, increasingly by the rest of the world which is beginning to pay attention to this trouble in west Africa.
If you contract Ebola in Monrovia, or anywhere near Monrovia, and you want the best chance of surviving your illness, the MSF ETU is the place to be. Ambulances containing new cases pull up frequently. I enquired, just in case, about MSF policy about hiring in the field. It doesn’t happen, which was disappointing, but at this time, only in a theoretical way.
This afternoon, I kept an appointment with the Medical Director of the JFK Memorial Hospital, Dr. Billy Johnson. JFK has been through a lot of institutional trauma in the past few months. This is discussed elsewhere in this chapter.
The hospital doesn’t treat EVD but it is on high alert for cases. The security screening for entry to the hospital is noteworthy. The intention of the screening is to discover, in the pool of people presenting with fevers and other significant illnesses, those patients with active Ebola. They are diverted to the MSF ETU. Otherwise, as has happened in the past, an unprotected phy-sician or nurse assessing a patient who turns out to have EVD, is at risk of contracting Ebola. [The deaths of several doctors at JFK from such interactions is discussed elsewhere].
The purpose of my visit was to learn about existing and proposed programs and projects related to the Ebola epidemic. Dr. Johnson outlined the situation from JFKs perspective. In addi-tion, we talked about exchange type programs in which medical students, residents, from over-seas, come to JFK or other institutions in Liberia, for medical work and learning.
Such exchanges would be a great experience for many medical professionals back home. If I were a medical student again, the chance to work in Liberia during an Ebola epidemic would be enticing. However, at this time, due to rules, regulations, insurance requirements, require-ments for medivacs if you contract Ebola, all combined to actually end the previous exchanges.
This seemed backwards to me but those were the facts.
I subsequently had a chat with the head of the Liberian medical college. My impression thus far, of men and women in positions of authority in the Liberian medical world, is that they are under a huge amount of pressure and stress, the result of dealing with the exigencies of this Ebola epidemic. Nobody says anything about it, but its real. At times I feel an almost fatherly sympathy for my Liberian colleages.
The meetings so far, had been helpful in giving me a greater understanding of the many aspects of the epidemic’s impact on Liberia in general and the medical profession specifically.
One morning I was sitting in an office, waiting for a scheduled appointment. Behind a spare wooden desk against the wall, a middleaged Liberian secretary did some paperwork while I waited. The phone rang and she picked up. I couldn’t understand what she was saying, but in the course of a minute long conversation she had, I picked up the words “white man.”
I suspected I was the subject of conversation, because I was the only white man within this institution at that time. She hung up the phone and said I’d be seen in about ten minutes. I thanked her. Then I asked her if she had a sheet of paper I could use. She reached into a desk drawer and pulled out a blank sheet of letter sized paper. I took it from her and then held it up to my face.
“This paper is white,” I said to her in a light-hearted way. “Do I look white to you?” She burst out laughing, as did I. But I would rather be a white man than a pink man.
SSAARRAASSOOTTAA SSHHAAKKEE
A newcomer to Monrovia is immediately stuck by the public’s alertness, attentiveness, to the Ebola epidemic. The streets are plastered with billboards offering Ebola advice. The many “Ebola is Real” billboards initially perplexed me. That message seems a bit trivial, I thought.
Above: AP photo of body retrieval team member spraying chloine on corpse. The presence of bodies on Monrovia's streets was a time limited phenomenon. Once the body retrieval
teams geaed up, more ambulances became available, this was a rare sight. Bless...
But I hadn’t yet learned that a major problem in preventing the spread of Ebola and of get-ting infected persons into isolation and treatment, was a widely held belief in the population that Ebola was not real, that EVD did not exist, that the purported epidemic was a nefarious plot. I learned that fairly normal Liberians actually, really truly believed Ebola was a hoax.
This disbelief was the precursor to many unnecessary deaths from Ebola. Thus the many billboards, attempting to counter what to me seemed to be an inexplicable and damaging misbe-lief. Perhaps the time for this unbelief had passed for most Monrovians because what I observed was an almost total adherence to the rules of not touching others, washing hands, having temper-
This seemed backwards to me but those were the facts.
I subsequently had a chat with the head of the Liberian medical college. My impression thus far, of men and women in positions of authority in the Liberian medical world, is that they are under a huge amount of pressure and stress, the result of dealing with the exigencies of this Ebola epidemic. Nobody says anything about it, but its real. At times I feel an almost fatherly sympathy for my Liberian colleages.
The meetings so far, had been helpful in giving me a greater understanding of the many aspects of the epidemic’s impact on Liberia in general and the medical profession specifically.
One morning I was sitting in an office, waiting for a scheduled appointment. Behind a spare wooden desk against the wall, a middleaged Liberian secretary did some paperwork while I waited. The phone rang and she picked up. I couldn’t understand what she was saying, but in the course of a minute long conversation she had, I picked up the words “white man.”
I suspected I was the subject of conversation, because I was the only white man within this institution at that time. She hung up the phone and said I’d be seen in about ten minutes. I thanked her. Then I asked her if she had a sheet of paper I could use. She reached into a desk drawer and pulled out a blank sheet of letter sized paper. I took it from her and then held it up to my face.
“This paper is white,” I said to her in a light-hearted way. “Do I look white to you?” She burst out laughing, as did I. But I would rather be a white man than a pink man.
SSAARRAASSOOTTAA SSHHAAKKEE
A newcomer to Monrovia is immediately stuck by the public’s alertness, attentiveness, to the Ebola epidemic. The streets are plastered with billboards offering Ebola advice. The many “Ebola is Real” billboards initially perplexed me. That message seems a bit trivial, I thought.
Above: AP photo of body retrieval team member spraying chloine on corpse. The presence of bodies on Monrovia's streets was a time limited phenomenon. Once the body retrieval
teams geaed up, more ambulances became available, this was a rare sight. Bless...
But I hadn’t yet learned that a major problem in preventing the spread of Ebola and of get-ting infected persons into isolation and treatment, was a widely held belief in the population that Ebola was not real, that EVD did not exist, that the purported epidemic was a nefarious plot. I learned that fairly normal Liberians actually, really truly believed Ebola was a hoax.
This disbelief was the precursor to many unnecessary deaths from Ebola. Thus the many billboards, attempting to counter what to me seemed to be an inexplicable and damaging misbe-lief. Perhaps the time for this unbelief had passed for most Monrovians because what I observed was an almost total adherence to the rules of not touching others, washing hands, having temper-
ature taken.
Every building, every business, every institution, had a hand washing station at the front door along with a security guard or two armed with an infrared thermometer. In the course of a normal day I would have my temperature taken ten times or more, and wash my hands in chlo-rinated water the same number of times,
The utility of frequent hand washing, with regard to the spread of Ebola, might be debata-ble. But doing it conveyed a sense of solidarity with all of society now facing a common enemy. After a week of meetings, visits and orientation in Monrovia, I began to experience parethesias in my fingers, and sometimes sharp, shooting pains in my hands. This was entirely without prec-edent and along with being uncomfortable, it puzzled me. Over a week, the problem slowly worsened. I broke my brain trying to come up with a rational explanation for these symptoms.
One morning I suddenly thought, perhaps this is related to constantly washing my hands in chlorinated water. I began to watch the untrained security guards preparing the water tanks used in the hand washing process. The amount of chlorine that was mixed into the water tank varied considerably without apparent regard for any system. At the end of a day of handwashing I noticed how strongly my hands smelled of chlorine. Now I could see why.
Although I wasn’t familiar with people experiencing chlorine toxcicity as the result of washing in water containing high concentrations of chlorine, I didn’t have any better theoretical explanations. From that day onwards, I faked my multiple daily ablutions, feeling slightly guilty as I washed my hands but scarcely got my hands wet.
Within two days my paresthesia resolved and the neuritic like problem ceased. I can only say that the ‘cure’ was correlated in time with my stopping handwashing. I thought of all the oth-er people who might be suffering similar side effects, but never met anyone who complained about it.
Every Monrovian knew the “no touching others” rule of Ebola prevention. Even little kids understood. For a short while I had to watch myself, the normal tendency to shake hands with a new acquaintance was almost automatic. But I soon got the hang of it. Absent a handshake or a “namaste”, the process of meeting other people felt incomplete, unsatisfying. I began trying out what I called the Sarasota shake, in honor of my granddaughter Amira who lived in Sarasota.
ABOVE: Monrovia. Body retrieval: A key element in plan to end this epidemic.
The Sarasota shake is simply an air handshake, just like playing air guitar. The Sarasota shake was an immediate hit. Not only was it fun, especially for kids, but you could shake the hands of five people in a short burst of shaking. It felt right and many of those who got the Sara-
ature taken.
Every building, every business, every institution, had a hand washing station at the front door along with a security guard or two armed with an infrared thermometer. In the course of a normal day I would have my temperature taken ten times or more, and wash my hands in chlo-rinated water the same number of times,
The utility of frequent hand washing, with regard to the spread of Ebola, might be debata-ble. But doing it conveyed a sense of solidarity with all of society now facing a common enemy. After a week of meetings, visits and orientation in Monrovia, I began to experience parethesias in my fingers, and sometimes sharp, shooting pains in my hands. This was entirely without prec-edent and along with being uncomfortable, it puzzled me. Over a week, the problem slowly worsened. I broke my brain trying to come up with a rational explanation for these symptoms.
One morning I suddenly thought, perhaps this is related to constantly washing my hands in chlorinated water. I began to watch the untrained security guards preparing the water tanks used in the hand washing process. The amount of chlorine that was mixed into the water tank varied considerably without apparent regard for any system. At the end of a day of handwashing I noticed how strongly my hands smelled of chlorine. Now I could see why.
Although I wasn’t familiar with people experiencing chlorine toxcicity as the result of washing in water containing high concentrations of chlorine, I didn’t have any better theoretical explanations. From that day onwards, I faked my multiple daily ablutions, feeling slightly guilty as I washed my hands but scarcely got my hands wet.
Within two days my paresthesia resolved and the neuritic like problem ceased. I can only say that the ‘cure’ was correlated in time with my stopping handwashing. I thought of all the oth-er people who might be suffering similar side effects, but never met anyone who complained about it.
Every Monrovian knew the “no touching others” rule of Ebola prevention. Even little kids understood. For a short while I had to watch myself, the normal tendency to shake hands with a new acquaintance was almost automatic. But I soon got the hang of it. Absent a handshake or a “namaste”, the process of meeting other people felt incomplete, unsatisfying. I began trying out what I called the Sarasota shake, in honor of my granddaughter Amira who lived in Sarasota.
ABOVE: Monrovia. Body retrieval: A key element in plan to end this epidemic.
The Sarasota shake is simply an air handshake, just like playing air guitar. The Sarasota shake was an immediate hit. Not only was it fun, especially for kids, but you could shake the hands of five people in a short burst of shaking. It felt right and many of those who got the Sara-
sota shake from me, went on to use it in their daily lives. Some foreigners greeted with the elbow bump but that method had no appeal, let alone the fact was it involved touching.
AA GGOOOODD SSAAMMAARRIITTAANN IISS AA DDEEAADD SSAAMMAARRIITTAANN
One observer in Monrovia wrote that Ebola is a destroyer of families. This is a deep and accurate characterization of the consequences of an Ebola epidemic. Ebola virus infection is a lethal disease. If you are in close contact with an active case of Ebola without having spacesuit type protection, you are likely to contract the disease yourself and die. Hardly anyone in Liberia — until recently, including medical personnel — possessed appropriate protective gear.
Prior to leaving for Liberia, I tried to imagine what it would be like to be a villager who's daughter becomes ill with Ebola. You have a wife and three other kids. If you care for your daughter under these circumstances, you will be infected by Ebola and likely die also. As will your wife and, at best, your other kids will live life as orphans.
In Liberia, this represents a real conundrum which has been faced by real people. Doing what a human should, resulted in the deaths of entire families, and this has occurred many times over the past months. Having to make such a brutal decision is a consequence of Ebola in west Africa and is likely the worst thing arising from the epidemic.
ABOVE: Body retrieval team at work in Sierra Leone.
Occasionally, despite the apparent inhumanity of the choice, the sick one is left to their fate. How does one live having made such a choice? Ebola victims who enter treatment, have a measureable survival rate.
It’s now apparent, that with an up to date capability for monitoring electrolytes, finessing hydration, and other care, the survival rate, especially for those detected early in the course of the Ebola infection, exceeds 90%. Knowing that if infected, you stand a great chance of surviving if you can only reach a modern ICU setting, could be dismaying if you are stuck in rural Liberia.
One lady in Monrovia became famous for nursing her Ebola infected husband to full re-covery. She constructed her own spacesuit out of garbage bags and kitchen gloves. Over several weeks she did her best to maintain her garbage bag protection. Her meticulous attention to changing her garbage bags, kept her from contracting Ebola during this process. Sounds possi-ble...
FFIILLOOVVIIRRUUSSEESS AANNDD HHUUMMAANNSS
Filoviruses, a category of viruses to which Ebola virus belongs, in the last 100,000 years have undoubtedly wiped out local populations they inadvertently infected, many times. These disasters have of course, gone unrecorded.
sota shake from me, went on to use it in their daily lives. Some foreigners greeted with the elbow bump but that method had no appeal, let alone the fact was it involved touching.
AA GGOOOODD SSAAMMAARRIITTAANN IISS AA DDEEAADD SSAAMMAARRIITTAANN
One observer in Monrovia wrote that Ebola is a destroyer of families. This is a deep and accurate characterization of the consequences of an Ebola epidemic. Ebola virus infection is a lethal disease. If you are in close contact with an active case of Ebola without having spacesuit type protection, you are likely to contract the disease yourself and die. Hardly anyone in Liberia — until recently, including medical personnel — possessed appropriate protective gear.
Prior to leaving for Liberia, I tried to imagine what it would be like to be a villager who's daughter becomes ill with Ebola. You have a wife and three other kids. If you care for your daughter under these circumstances, you will be infected by Ebola and likely die also. As will your wife and, at best, your other kids will live life as orphans.
In Liberia, this represents a real conundrum which has been faced by real people. Doing what a human should, resulted in the deaths of entire families, and this has occurred many times over the past months. Having to make such a brutal decision is a consequence of Ebola in west Africa and is likely the worst thing arising from the epidemic.
ABOVE: Body retrieval team at work in Sierra Leone.
Occasionally, despite the apparent inhumanity of the choice, the sick one is left to their fate. How does one live having made such a choice? Ebola victims who enter treatment, have a measureable survival rate.
It’s now apparent, that with an up to date capability for monitoring electrolytes, finessing hydration, and other care, the survival rate, especially for those detected early in the course of the Ebola infection, exceeds 90%. Knowing that if infected, you stand a great chance of surviving if you can only reach a modern ICU setting, could be dismaying if you are stuck in rural Liberia.
One lady in Monrovia became famous for nursing her Ebola infected husband to full re-covery. She constructed her own spacesuit out of garbage bags and kitchen gloves. Over several weeks she did her best to maintain her garbage bag protection. Her meticulous attention to changing her garbage bags, kept her from contracting Ebola during this process. Sounds possi-ble...
FFIILLOOVVIIRRUUSSEESS AANNDD HHUUMMAANNSS
Filoviruses, a category of viruses to which Ebola virus belongs, in the last 100,000 years have undoubtedly wiped out local populations they inadvertently infected, many times. These disasters have of course, gone unrecorded.
FFAAIILLUURREE TTOO OORRIIEENNTT
I’d been in Monrovia for nearly two weeks, when I realized that the city still seemed con-fusing to me, difficult to orient my self to, to internalize a map of the place. Since I was usually quick to create an internal map of a new location, I was puzzled. A few days later a possible ex-planation popped into my head.
As James and I drove along in Monrovia, I had been observing how the shadows of vehi-cles, people, other structures, were quite minimal. The sun was high overhead in this city, near the equator, and the shadows cast for much of the day, were created by an almost vertical light. I realized that I hardly had ever seen the sun since I arrived. It was out every day of course, but stationed directly over my head, out of sight and out of mind.
Previously, when orienting myself in a new environment, I became aware early in the pro-cess of north, south, east and west. My brain most likely linked this awareness to the sun location in the sky. This established the foundation for the rest of the mental map which quickly con-structed itself. Near the equator, my basic cues are absent, and disorientation is the result.
This theory makes sense to me and I’m sticking to it, at least until a better theory comes along. I won’t consider any theories however, which contain the words prion, dementia or dam-age.
MMOONNRROOVVIIAA UUNNIITTEEDD
The boys in the photo below spent their out of school days engaged in an unending game of soccer near one of the businesses I visited from time to time. They seemed oblivious to the problems arising from using a tin can as a soccer ball. A solution to their problem was at hand.
Above: A street soccer team in Monrovia. Switching them from a tin can to a real ball
took their game to a whole new level.
TTOOOO MMAANNYY MMAAPPSS
This morning I located the WHO office in Monrovia. Without really asking, I was di-rected to the professionals office on the top floor. Alone in this airconditioned space, I discov-ered the most detailed, wonderful map of Liberia, a map for which I’d been searching for all of my Liberian life.
I looked around for someone to talk to but the staff seemed to have vanished. The map was tacked to the wall with four small pins, easily removable pins. I looked them over carefully. Then I realized that I was in mortal danger of committing an unforgivable cartographic sin. So I left.
Leaving the building I met a knowledgeable employee who told me that the best place to obtain maps was a certain building at the other end of Monrovia. James and I drove over and lo-
cated the building. It didn’t look like the kind of building which contained really good maps, but I went in anyway. On the second floor, a nondescript door led into an airconditioned war room filled with busy people and computers.
At the far end, sitting behind a plain wooden table, looking like they were running a poor-ly stocked lemonade stand, were Officers Frank and Willis of the US Army. I explained that I was looking for maps of Liberia.
“Exactly what kind of map would you like doc?” Officer Frank asked.
“Ideally, I’d like a 1:25000 of all of Liberia,” I replied. “You know, at that scale doc you’d have too many maps,” he explained. “I’ll get you the
best scale. I have a data pipe into our map archive and can print you out a map at any scale for any location on earth.”
I was shocked. Doubly shocked. First of all, what kind of man had a data pipe and could create a map at any scale of any place in the world? Had I met a cartographic god? Officer Frank was a solid looking dude, resembling a granite monolith excavated at Tell Megiddo. But never once, since the day I was born, had I met someone like this.
Secondly, I was stunned by the concept of a man who had to many maps. Never since the day I was born, had I dreamt that such a creature could exist. I certainly, no matter how large my collection, would never attain the status as one who had too many maps. Trying not to drool, or fall to my knees in thankfulness, I accepted his offer and put in my order, the maps to be picked up in a couple of days. What a great office this turned out to be.
IIMMSS MMEEEETTIINNGG
Towards the end of my first week in Monrovia, serendipity led me to the room where the President’s Incident Management XX held it’s meetings, three mornings per week. The IMS I learned was basically the President’s Ebola Response Team.
I didn’t realize at first what the nature of the meeting was. I saw the meeting room that morning, a conference table at it’s center, men with suits and well dressed women seated around it, my interest perked up. That the outside entrance to this room, was populated by camera men and other media, added to the cachet of the meeting. The clincher was the guard at the door who monitored access and took the names of those he let enter.
When the door guard was distracted explaining something to a media person seeking en-try, I opened the door and walked into the room. I only mention this because things like this make me nervous. The only vacant chair in the room was at the front beside the Chairman’s seat at the table.
I sucked up my breath, looked serious and walked as steadily as possible across the room, heading for the seat. It seemed to take forever to get to the seat which kept receding as if I were in an Alice in Wonderland play. As I passed by the attendees seated around the table, through the corner of my eye I read their placeholders. Impressive, World Bank, UNICEF, CDC, WHO, Li-berian government ministers, and so on. This team was responsible for everything to do with Ebola in Liberia, all logistics, planning, funds, and so on.
Upon finally reaching the empty chair, I sat down feeling conspicuous, though no one had paid any attention to me. Pulling out my notebook and my stern face, I listened in on the conver-sation.
After attending several meetings, I was on a first name basis with many of the team mem-bers. I got to know their programs, solicit their opinions, debate their predictions, and understand some of the problems they faced, which ranged from material resources to human stupidity. My presence was innocuous and unnoticed and though I never interfered with anything, my attend-ance at the IMS meetings, gave me a first hand, real time understanding of the state of the Ebola epidemic in Liberia.
The specifics of these meetings was kept confidential. The contacts derived from these meetings, the information learned, were essential to deriving answers to my self-created ques-tions, which were the reasons for my journey to Liberia.
AAFFRRIICCAANN PPEEAARRLLSS
Not long after arriving in Monrovia, I met a group of survivors of Ebola and began to learn from them firsthand, about the astounding events in their recent past. Contracting Ebola
virus, by great good fortune surviving the illness, then dealing with the almost invariable fact that your mother or father or both, had died, along with other family members. The general population is afraid of survivors and they are shunned, avoided and isolated from those they knew in their pre-ebola lives. Children are stigmatized perhaps even more severely. They cer-tainly take the inexplicable discrimination to heart. Just learning about this, seeing it happen, it's all hard to take.
I made a special point of meeting with survivors, of helping them organize groups through which they might project their plight, and seek redress from, with greater authority.
By the end of my first week in Monrovia, after just a couple of meetings with survivors, two simple thoughts popped into my head.
First, a noble mission as yet unfulfilled is for an individual or a group, perhaps a writers club, to self-fund a project to document the stories of Ebola survivors. Recording their stories, letting them share them with the world, would at least for the older survivors, improve their self-image and their lives. They all seem anxious to tell their stories once they determine that they have a sympathetic, or nonjudgemental listener.
So, researching and writing this book, or books, is a mission open to anyone willing to engage in a truly noble task.
The second idea is to induct survivors into the Order of the Pearls of West Africa. Because the truth is that a survivor has been blessed by providence, that they are the safest people in the Ebola affected countries, that their ebola antibody laden blood may be more valuable than gold, each survivor will be awarded, perhaps by the President, with a handsome medallion to wear on their shirt, or perhaps to wear on an armband.
The medallion would depict a solitary Pearl, which represents the survivor. It would be framed by a necklace of Pearls, strung together in elegant harmony. This would represent the en-tire cadre of survivors in all the three countries who are bound together by their common experi-ences. A little kid, currently shunned or being picked on because he's a survivor, would be able to go to school with this great medallion, awarded to him by the President, pinned to his shirt.
Two noble projects waiting to be realized. Elsewhere I've mentioned the project of prepar-ing a book which provides the stories of the more than three hundred doctors and nurses who have died in this epidemic so far. Recording their stories will create a shining star in the shadowy firmament of history, something which everyone can be proud of, and will honor those who served.
SURVIVOR DISCRIMINATION [?DUPLICATION} The general discrimination against those who were infected by Ebola but survived the dis-
ease, took some getting used to. The only way I could understand it was to put aside the knowledge that the survivors are not capable of transmitting ebola to others. They don't carry the virus, but they do carry something that likely is quite valuable, a circulatiory systems charged with high titers of antibodies against the Ebola virus.
Separating blood components so that the antibody carrying plasma is available to be in-fused into those with active Ebola infections has apparently done wonders for some. Survivors should be mined and then compensated for their plasma at a rate commesurate with it's value. They'd be rich.
Children who have survived Ebola are especially damaged by the irrational discrimination they face by both other children and adults. This is a powerful negative element in society.
At one meeting of survivors that I attended, I hugged one survivor to the immediate aston-ishment of the rest of the group. I explained that as a doctor, I knew that there were two kinds of people in Liberia. One group, consisting of survivors, I called the huggables.
As for everyone else in the country, I had no idea of their status vis a vis Ebola and I called the the untouchables.
Planned to design an armband or medallion commemorating the status of a survivor, a medallion the President could present to each child who was a survivor. The kid could go to school and instead of being shunned, would be the proud possessor of a beautiful "Pearl of Afri-ca" medallion received from the hand of the President of Liberia.
The sadness of many of the survivors experiences was almost unbearable. Sitting beside a 16 year old boy, a good student in school [formerly], a young man with ambition, a good support system, his future until Ebola boded well.
During a couple of weeks in August, first his mother got infected with Ebola, and then his father. They died within days of each other. He also fell ill, but survived. Now he's alone in the universe, an orphan shunned by relatives and much of society, living alone on a mere pittance, unemployed, with a future that is clouded with storm cells.
"I'm alone," he kept saying, to no one in particular, as I talked with him. Every few minutes, no marrer what we were discussing, he'd sigh and in a quiet voice say "I'm all alone."
His face displayed the visage of a shell shocked soldier. I did not have anything to offer him. Nothing to make it better. I remembered my life when I was sixteen, and it was such that I couldn't even have imagined what this young man had gone through and now faced for the rest of his life.
There were many such people I met. And each unbelievable experience I heard, seemed to stick to me, somewhere inside it just stuck and this pile of things that couldn't be made better, that existed as the counterpunctual note in the orchestra of life's possibility, became a heavy con-stant presence.
I did not know how to get rid of it, or even wall it off, so I could spend some time in igno-rance of this pile of sadness...
GGEECCKKOOSS WWIITTHHOOUUTT BBOORRDDEERRSS OOCCTT 1188 One night as I was composing an email for Ben, I began thinking of the geckos he loves
so much. Liberia supports a variety of geckos, generally larger than Ben's, but not as colorful. I was motivated by the malaria bearing mosquitos that cruised through my airspace at night, to propose to Ben that he train up a gecko and form a group called Geckos Without Borders. A member of GWB would be trained to sleep in your shirt pocket during the day. But at night, when you settled down for a nights sleep, he would emerge from your pocket and roam the walls and ceiling of your dark bedroom, gobbling down disease vectors of all varieties.
In the morning, you would put two fingers to your lips and whistle for him He would come down to your bed and curl up in your pocket, resting in preparation for another nights work.
I mentioned that when I'd first gotten to Monrovia, due to all the NGO personnel and the pending appearance of the 101 Airborne, many of the hotels and lving space were full. I spent a day searching for that unique institution, a Hotel Without Boarders.
BBEENN''SS GGEECCKKOO SSAALLEE
Back home, Ben had organized a special sale of his geckos, his business, with the pro-ceeds to go to this project. It went off very well, and I was surprised at how good something like this can make you feel when you are overseas and apart from most things that you know. Good work Big Ben.
DDAANNCCIINNGG IINN TTHHEE SSTTRREEEETTSS
James and I were driving back to Monrovia from the MSF Ebola Treatment Unit on the airport highway. Halfway back to Congo Town the highway was partially blocked with a pile of tree branches and a few posts. All the traffic had to divert around one side of this crude barri-cade.
Protected by the barricade, three young men in torn clothes, were busily at work on an as-teroid sized pothole. Equipped with a couple of rickety pails, a crude looking shovel and a wheelbarrow that must have come over on the Mayflower, they dug up mud in the field beside the highway, filled up their wheelbarrow, rolled it over to the pothole and then packed in down into the hole.
The pothole was gargantuan but in Liberia it wasn't unusual. Every road in Liberia is 50% pothole and 50% bad road.[Except for the road around the US Embassy in Monrovia. I discov-ered this stretch of road in the course of visiting the Embassy on business one day. This half mile or so of Interstate quality road, in the midst of Monrovia was astounding. Driving along it, James car was quiet, the ride was smoother than I could remember.
"Drive it again, James," I told him when we reached the end of the road. So he turned the car around and we drove it again. But that road is the exception.]
The three raggedy looking young men filling the pothole on airport road were such an un-
likely looking city repair crew that I asked James, "Are those guys working for the city?"
James laughed. "No, no body works for the city. Nobody fixes potholes. These guys are do-ing it and hope that someone driving by will give them a few cents."
I was impressed. Their initiative, especially in this environment, was monumental. In this land without work -- healthy young men have an 80% unemployment rate] for the thousands of eager young Liberians, the commonest reaction was to give up. These three guys on their own initiative wee digging mud and filling in potholes on one of the busiest roads in the region.
I had three one dollar bills in my pocket and pulled them out. "James, please stop here," I said and rolled down my window. We stopped beside the men, one of whom came up to my opone window with a pensive look on his face. James, who by now had learned to speak for me told the young man the dollars were for the three of them for doing such a good work. The man quietly took the three bills, and as James drove off, I rolled up my window, thinking that the man's reaction was rather muted.
We'd driven about a hundred feet when James, looking back in the rear view mirror, said: "They are dancing in the street."
What? I thought. I turned around in my seat and looked out the rear window. Behind us, dancing around the perimeter of the half filled pothole, the three men performed the Liberian dance of happiness, each grinning man waving a dollar bill in his hand.
"They are very happy," James added unnecessarily.
PPOOLLIICCEE SSHHAAKKEEDDOOWWNNSS
When visible, the Liberian police in Monrovia are usually engaged in just one activity, shaking down drivers for bribes. Two or three times a day, depending on the traffic, the police appear on Monrovia's streets and begin segregating passing traffic.
One cop will stand in the road, in the traffic. He holds one arm up and watches the ap-proaching vehicles until his next victim comes into view. He wiggles one finger at the driver and the victim is required to pull of to the side of the road where another small group of cops are hanging out.
A cop then comes over to your car and looks it over carefully, searching for any violations of the law. He checks the driver's papers in great detail. Once a deficiency is discovered, no mat-ter how trivial, the options are to pay a bribe or to go to jail. These cops remind me of vultures hunting prey. On Saturdays, the problem is even worse because more cops come out to shake-down the population.
"Sunday is a quiet day. There's much less traffic. The cops can't make any money on Sun-days, so they work twice as hard on Saturdays," I was told.
To experience this even once, is degrading and the selection process has deep and horrible connotations. We are pulled over at least once every day. Every time James has to be released without a problem because his car and paperwork are meticulous.
"I can't get into any trouble," he told me. "I have to look after my mother and my wife and kids. If I go away, there's no one for them."
I felt like taking the cops finger and shoving it where the sun didn't shine. But in Monro-via, the assumption that the consequences of messing with a cop are similar to those at home, would be to make a painful and time consuming mistake, if not a lethal mistake. Law and order are as evanescant as a morning fog. Nothing can be depended on.
FFAAKKIINNGG EEBBOOLLAA NNOOTT SSOO WWIISSEE
One day, we got the wiggle finger three times. Each time, squeeky clean James came out of it with nothing but time wasted. I hadn't been in Liberia long, so I wasn't really tuned in to consequences and I was very sensitive to these constant affronts to civilized behavior.
As we pulled away from our third detention, I said to James: "Next time we get pulled over James, I'm going to pretend I'm very sick with Ebola. You
tell the cop that you are driving me to the Ebola Treatment Unit. They will run away and we can go on."
James didn't seem to put much credence in my statement. But the next day, late in the morning on Tubman Street, we drove into another police shakedown. A line of cars waiting to be
predated lined up on our right. We were stopped in a parallel line. A cop walked towards us in the space between the two lines. When he reached the front of James vehicle, I grabbed my stomach, and curled up in the passenger seat, moaning loudly as I attempted to writh in pain.
Expecting any second to hear James confronted by the cop, I was surprised when James put the car in gear and pulled away from the police stop. He was laughing so hard he could hard-ly steer the vehicle. My Ebolic agony triggered a serious bout of laughter. As we drove away, he was still laughing uproariously.
I sat up and in a minute or so, James settled down. "James, if the cop sees you laughing like that when you say you're taking me to the ETU, I
don't think this is going to work."
He tried to look serious as he listened, but he wasn't very good at it. With the benefit of a few more days experience of Liberia, I would not have suggested faking EVD in order to evade a police shakedown. Consequences could be surprisingly unpleasant.
AANNTT AARRTT
Tonight in my successful attempt to email home, I wrote to Amira about a new art form I was exploring. Serendipity triggered the observations on how tiny red ants that prowled my room, responded to the discovery of a raison or half peanut that fell from my trail mix lunches.
The ant who made the initial discovery of a raison, sometimes hung around exploring it's raisony vastness, but then would leave the raison in the direction of his home [I assume]. Not too long thereafter a few more of these tiny critters would show up and the serious business of raison transportation occupied their attention.
The fact was that these tiny ants could not move a raison. But they liked raisons and a rai-son on the floor would soon be crawling with admirers. The newcomers would follow the early ant's trail but many took shortcuts which established new trails to access the raison.
Eventually I learned alot about the hiking habits of little red Liberian ants. This enabled me to begin placing raisons at strategic places on the floor, outlining a human face with raisons placed in a manner that kept the ant trail to a single file.
I led the trail up to the first raison, then on to the second raison and so on. Finally [about one out of three attempts resulted in art] a small area on my floor about two square feet, became a living depiction of a human face. When successful, I ended up with a raison face that was a moving mass of tiny red ants. I don't know if I'm the first person to invent this process, and alt-hough the final product was noteworthy, I believe that most people would consider it a waste of time.
WWHHOO''SS DDEERREELLIICCTTIIOONN
I resisted jumping to any conclusions as to the explanation for the anomalous spread and the unprecedented magnitude of the current Ebola epidemic. But, as the weeks passed, and my information became accurate, timely and authoritative, the accumulating evidence pointed a fin-ger in the direction of WHO.
The primary cause of this mandemic, based on this evidence, is the botched response of WHO. All the evidence indicated that WHO’s response to this epidemic, demonstrated the or-ganizations ineptitude and incompetence — especially WHOs lack of response or inaction in the face of a major threat.
I didn’t hold this conclusion yet, but I’d not encountered any other significant explana-tions, or learned of any other factors, that could account for the disaster. That WHOs funding was cut significantly in the few years previous to the epidemic, could have played a role.
How could such a dereliction of duty happen? What does staff have not to do in order to generate such deadly inaction? I don't know. But those in the know state without question that WHO is incompetent, their staff is irresponsible and incompetent, and if WHO had done the job it was created to do, instead of more than 5000 deaths in west Africa, there may have been fewer than twenty. That's an astounding conclusion.
The most thorough investigation of WHO and its inaction is necessary in order to deter-mine how the problem arose, and how to fix it. The least of the consequences should be the mass firing of a malpracticing staff.
While I continued to search for other factors that facilitated this deadly epidemic, the evi-dence it had a human source, human failure at the source, if true, meant that one of the questions behind my journey to Liberia, had an answer. Furthermore, I didn’t feel I could pursue this as-pect of the quest any further. I trusted that there were people who could and would break it down to the core and figure out what WHOs disease is.
EEVVEERRYYTTHHIINNGG IISS HHEELLPPFFUULL A few weeks in Monrovia led me to the conclusion that just about anything one does here,
leads to an improvement in someone else's life.
For example, if you dropped a twenty dollar bill on the street, while it would be lost to you, you know that who ever finds it will be hungry, needy, without vices like smoking, and that your twenty will go into the purchase of food and other essentials for a needy family.
Everything can be used by someone. If I fell out of bed in the morning, in some mysteri-ous way, this would improve the life of someone else in the city.
CCDDCC SSUUGGGGEESSTTIIOONNSS Via the news one night, I heard the idea proposed in the US to make sure that every major
hospital in the country was geared up and trained to handle patients with EVD. That is possibly the worst idea in the entire world. Filoviruses are brothers from another mother and from a dis-tance at least, it appeared that the highest authorities in the US did not get it. Ebola, in the best of circumstances is almost in a troublemaker class of its own.
The country should develop a handful of centers with the staff and facilities capable of dealing with EVD. Perhaps two on the west coast, two on the east coast and two in the middle coast. Served by specially provisioned teams on aircraft, any EVD patient in the country could be safely transported to a treatment center within an hour of diagnosis.
I'm not sure if you could take five hundred medical personnel, all of them totally motivat-ed and competent, and train them to put on and take off PPE twice a day for three weeks, without having an irreducible 5% of them dying of Ebola. That kind of perfection is necessary but not everyone is capable. Perhaps it's an art.
BBIIGG JJOOHHNN
The failed understanding that calls for every major hospital to have Ebola treatment capa-bility was based on, reminded me of the story of Big John. One day long ago on the western frontier, in a saloon in a small cattle town, a group of cowboys had gathered to wet their whis-tles. Suddenly the placid character of the afternoon was broken. A cowboy rushed into the sa-loon, standing breathlessly infront of the bar’s patrons.
“Run everybody,” he yelled. “Big John’s coming!” Cries of “Big John’s coming!” filled the saloon as the patrons scattered for the exits, sev-
eral leaping through the glass windows, in a frantic rush to escape. In seconds, the previously crowded saloon was empty, except for the aproned bar keeper. When he heard big john was com-ing, he had dropped everything and began running for the exit, but as he rounded the corner of the bar, his apron strings hooked onto a nail, and he was jerked to a stop.
As the barkeeper feverishly worked to release himself from the nail, out front, coming down the town’s main street, came a huge man the likes of which had never been seen before in those parts. He was mounted on a buffalo, but even so his feet dragged along in the dirt as he rode closer. Under his right arm he had a snarling mountain lion pinned to his chest. Under his right arm, a thousand pound grizzly struggled helplessly to free himself from this man.
The buffalo walked right up to the front door of the saloon. Throwing the mountain lion and the grizzly bear down onto the street, the giant dismounted. In one stride he was at the sa-loon’s front door. With one flick of his powerful right arm he smashed the saloon’s door off their frame and then he stepped into the saloon.
The entangled saloon keeper froze when the big man walked into his saloon. Trembling in fearful silence, the barkeeper watched the man approach.
“Give me a whiskey and make it snappy,” he demanded, his deep powerful voice rattling the saloons wooden frame.
“Yes sir,” the saloon keeper stuttered, scarcely able to move in fear. But he finally got his
apron strings unhooked from the nail. He reached behind the bar, pulled out a bottle and was be-ginning to pour the big man a drink. But the man grabbed the bottle from his hand, put the end in his mouth and chewed the glass through. Then he tipped the whiskey bottle back and drank it down in one long gulp.
When he finished the bottle, he smashed it to the floor and stared at the barkeeper.
“Would you like another sir?” the barkeeper asked in a tremulous voice. “Hell no,” the man said loudly. “I’m gettin outta town. Haven’t you heard? Big John’s
coming!”
RRAADDIIOO RROOGGEERR
One afternoon as James and I were driving to a group meeting of Ebola survivors, James turned his car radio on to a station that had a call in show on which the topic centered on Ebola. After a few calls and discussions, when the host of the show picked up the next call, listeners heard what sounded like a child’s voice.
His name was Roger. His mother was outside.
He didn’t want to get her. He wouldn’t hang up and the host apparently could not disconnect him without his coop-
eration which he wasn’t getting.
He finally got Roger to hang up. His call in phone rang again, and it was Roger. This had been going on for around five minutes. Once again Roger wanted to discuss a toy that he like and he wouldn’t hang up. After a few minutes of hilarious conversation with the five year old boy, the kid hung up again.
The host said a few restrained words about Roger, seemed to take a deep breath and then opened up the lines for the next caller. The phone rang and when he answered it, we heard Roger say hello.
James and I had a good laugh.
“James, I think we just heard the voice of a future President of Liberia!” I said.
MMOOUUSSEE DDIIEEDD
One evening I had access to a frumpy computer belonging to the owner of the apartments I was living in. I sat at the desk trying to get the computer working but the hand mouse wasn't working. I tried a number of fixes without success. I discovered that when I touched the metal from of the power supply that an electric tingle shot into me. [I warned the owner about this,]
But after my failed attempts to get the mouse working, I turned from the desk, to the own-er who was in his office talking with two other men.
"The mouse has died. Will you please call the body retrieval team for me," I said, with a small smile. I thought it might be amusing, a one on the scale of one to 100.
To my surprise and puzzlement, the entire group of men began laughing so lustily, I was afraid for their health. This was the kind of laugh that the funniest joke in the world got on Monty Python. They eventually settled down. Perhaps I was trying to puzzle out things that were never meant to be unpuzzled.
But I finally decided that the repressed fears and anxieties which the Liberians I was meet-ing experienced, Ebola induced anxieties which people stuffed inside themselves so they could function in normal life, had somehow been touched by the idea of a mouse dying of Ebola and of having to be transported by the body retrieval team to the cemetery.
But, who knows. I do know I'm not that funny.
WWHHEEEELLCCHHAAIIRR MMEENN,, AAMMPPUUTTEEEESS This is a depressing problem to observe, let alone be personally involved. There is no so-
cial security net to rely on. If you've had your legs shot off in the recent war, you now have to survive on your own without any organized help from anyone or any group. The population that falls into this category consists of young men who once had futures to look forward to but who are now wheeling broken down wheelchairs through the crowded streets of Monrovia.
These men are eager to be of some service, to exchange work for compensation, to be of some value to others. I say that on the basis of having talked with a fair number of different war victims. When I talk with them, and hear their stories, my insides just cramp up in despair. There is nothing that can be done to improve this situation. Maybe if I were a millionaire, but right now, there's nothing but dismay at the inequity of lifes treatment of many human beings.
James and I made a great friend in downtown Monrovia one day, an older man mission both his legs, who maneuvered his old wheelchair over the broken sidewalks and holy streets. We first met him when we were trying to back out of a parking spot, into a street filled with traf-fic. No one would let us in. Suddenly we saw this man roll his wheelchair into the traffic on the street behind us. Maneuvering his chair, he quickly blocked the vehicles behind us and we were able to back out easily.
I loved his initiative; how cool. I asked James to stop and I gave our traffic assistant a dol-lar bill. He was deeply grateful for the buck, which is a good chunk of change in these circum-stances. But I could also see in his face a sense of having performed a service for pay and that he was thrilled to have done it.
Thereafter, whenever we were downtown, we tried to park in this man's neighborhood. He almost always showed up, took charge of the traffic on the street and got us on the way pronto. I loved paying him for his services. I wished I could do something that would create long term im-provements in his life. But ...
He and I live on the same planet. In fact, we are normally just 48 hours apart, by air. Yet the opportunities and bounty I take for granted at home, are unattainable in his world. How can such a dichotomy exist on the same planet? I'm not being naive here, but if you sit down on Voyager 1, you'd conclude that all human beings actually reside in one house, and wouldn't tol-erate such inequities.
Part of the reason these conditions both exist and persist, is the damaging consequences arising from the system of nation states. What a bogus idea. How insulting to one's intelligence to suggest that because that man lives on the other side of this river, he's subject to different laws, can be misused as a human being without your having any say in the matter. What a crock. However, I believe that the times they are a changing, primarily as the result of technology de-grading the conceit of they are over there ane we are over here. Every person I met in Liberia can Skype with you now, and explain the dilema.
The McDonalds theory of intenational warfare is an exemplar of this ongoing process.
LLIIBBEERRIIAANN CCRRAACCKKEERR
It’s my third Sunday in Monrovia, and I’m starved. For the past two weeks I’d lived on trail mix and water, which is an excellent diet in situations in which you are being careful not to acquire a gastrointestinal bug.
After I ran out of trail mix, I switched to Coke and crackers. What this dietary decision was based on, I don’t remember. Early yesterday I ran out of crackers but since I wasn’t hungry, decided I’d wait till Sunday to stock up again. Now it was Sunday and my stomach was rum-bling. I headed out to replentish my supplies and to my chagrin, discovered that Monrovia to a large degree shuts down on Sundays.
Now I’m really starved, but have no choice but to get through to Monday. I thought per-haps I should just go out and wander the streets of Monrovia in search of a cracker. Then I real-ized that if a white man is roaming the streets of black Monrovia in search of a cracker, all he really has to do to find one is look in the mirror.
SSKKII JJAACCKKEETTSS One hot afternoon James and I were in downtown Monrovia, when I was struck by how
many Liberians on the street were walking in the hot sun while wearing ski jackets. Some wore full fledged parka similar to what you might see on the slopes in winter at home. This was diffi-cult to explain, or even to think of a reasonable explanation for. I thought, at first, perhaps there's some genetic variant in Liberia which is generating a group of cold intolerant people. But that struck me as highly unlikely.
So I asked James why all these people, in the heat of the day, are wearing ski jackets, par-kas, substantial winter clothes.
"Most of them come into Monrovia on the small motor buses. They are so packed in with
people that everyone is touching each other, squeezed together. So they wear heavy clothes so they don't have to touch others and get Ebola," he explained. That made sense.
Monrovia was full of little buses similar to a VW microvan. They were all stuffed to the hilt with passengers. I was in favor of avoid this type of public transportation. Not only was it uncomfortable, but the fact was there was a nonzero risk of being put in close physical contact with a person suffering an active Ebola infection.
James explanation was one of many he gave me in response to my incessant questioning about everything in Liberia. His explanations always felt intuitively correct. I am now convinced that there is nothing in Liberia, no matter how strange or mysterious it may seem, that James can't produce a rational explanation for.
I think the only thing James learned from me during the entire time I worked with him, was how to identify the counterfeit bills that circulated freely in Monrovia. Most were easily de-tected. I was surprised that he wasn't aware of this. Fortunately, I guess, since the counterfeits circulate as readily as the genuine bills, and no one ends up without a chair when the music stops, the most efficient procedure is just to spend your counterfeits as soon as you can. They are no good at home.
PPUUBBLLIICC SSMMOOKKIINNGG BBAANNNNEEDD
I mentioned to James this morning that in all the time I'd been in Liberia, I had not seen a single person smoking. How amazing. He said that smoking in public is banned.
MMAAJJOORR GGEENNEERRAALL VVOOLLEESSKKYY
The 101st Airborne got down to work upon their arrival in Liberia. They are building ETUs in various parts of the country and are involved in improving regional communications and logistics. Everything they do is a leg up for Liberia and the anti-ebola people. The operation is commanded by Major General Volesky, who I had the pleasure of meeting at the morning IMS SitRep.
What an interesting man. He is, perhaps of necessity, socially adept. He must meet and in-teract with hundreds of people many of them civilians. During the meeting, at which the General was introduced to the team, he sat at the conference table beside the Chairman.
During the meeting, I happened to glance at the General who, no longer the subject of at-tention, was free to be himself. He now had the appearance of a man on a mission. As he sat qui-etly at the table, his eyes roamed the room and the others at the table, almost like laser beams, taking in every detail, assessing everything in his sight.
That’s what it appeared to be like to me. His intensity seemed to manifest itself in a glow. I could see why he achieved the high status he had. He was clearly a man who was used to get-ting things done, done now and done his way.
BBRRAASSSS
As the international response to the Ebola epidemic finally began to ramp up, the IMS meetings attracted alot of VIPs.
This morning Major General Volesky, was introduced to the team. I met his assistant, Lt. Col. Rossr Lightsley, a man I enjoyed conversing with. The were present in the form of the Brit-ish Liason Officer for Operation United Assistance named Lt. Col. Julian Pemberton-Pigott. He is quite a conversationalist. Our conversations ranged from Ebola to the Falklands, military strat-egy and tactics, and the local situation. I know that on military points he’d be coddling me, but I learned a lot.
The meeting room thus included Major General Volesky, Lt. Col. Lightsey,US Army an-cillary staff, a German general and I believe a Dutch general, along with two Majors from the Chinese People’s Army. [I believe that in the Chinese Army a Major is even a bigger star than the same rank in the west].
I was seated to the right of Lt. Col. Julian Pemberton-Pigott and we’d enjoyed a good conversation prior to the meeting. As the room quieted and the meeting began, the Lt. Col. leaned over and whispered to me: “Back when I was a Corporal, if I’d have walked into a room filled with this much brass, I would have passed out.”
Above: Major General Volesky, Commander of the 101st Airborne, and head of US re-
lief operations in Liberia. The General is on the right. I'm on the left.
LLEESSSS TTRRAAGGEEDDYY
My emails home contain cheerful comments and observations. I realized after some time that I was so self censoring that my crew at home might conclude that the troubles in Liberia were minor, an inconvenience rather than a catastrophe. So I mentioned this thought to my crew. The difficulties in the lives of others overwhelm me at times. I can only imagine how they are impacted. There are really just too many things to cry over, so it's no use starting.
FFEEWWEERR AAMMBBUULLAANNCCEESS
Many disparate data sources began to suggest to the IMS that the Ebola epidemic had un-dergone a phase shift, a transition to another form. Shortly after this consideration had been broached in the IMS meeting, another line of evidence appeared, that strengthened the impres-sion that the epidemic was 'decreasing' and that the elements that sustain it, the mode of trans-mission and so on, was also changing in significant way.
MSF told the meeting that it had 50 empty beds in it's ETU. They speculated that this could be due to a decrease in new Ebola cases. Or perhaps the persistent fears in the community about hospitals and doctors, made more people afraid to present and they were dying elsewhere.
However, MSF stated that more patients presented at the ETU arriving in private vehicles, rather than by ambulance. That would suggest that the message proclaimed to the public that if you get ill, the best results occur if you get diagnosed early.
There's so much unknowing though. Often diametrically opposed interpretations of am-biguous data, each leading to greatly differing conclusions.
One report in this meeting, an anecdote offered to reinforce the need not to let one's guard down. A family in Monrovia last week buried a member who'd died of Ebola. It wasn't a safe burial , and as a result all the other seven members of this family now had EVD.
Am exactly where I should be doing exactly what I should be doing...
One of the last IMS SitRep meetings I attended prior to returning home, was quite en-couraging. Based on the reports from a number of organizations, the epidemiologists, and so on, the meeting concluded that there are valid, trustworthy indications that the Ebola epidemic in Liberia has significantly improved and should continue to improve.
This was the first time such conclusions could legitimately be extracted from the availa-ble daya. The quality and amount of epidemic related data had improved considerably, week by week. Dr. Dolo made a short talk, a prescient talk, in which he suggested that we were probably detecting a significant change in the behavior of the epidemic.
A phase shift, and that the entire group should examine the circumstances to determine if the present course of action remained the best.
If the national case load was dropping to the point where there were only ten or less ebola patients in Monrovia, the utility of construcitng facilities with hundreds of beds for ebola pa-tients, a project now under way, might be low. We might have to revamp our entire approach he said. I believe he was correct and prescient.
The Sarasota shake is thriving in certain neighborhoods.
EETTUU IIDDEEAASS Despite my lack of expertise in design and construction, I came up with a few “inven-
tions” that I felt might assist in dealing with the Ebola epidemic. Nothing came of them, but I though they had potential.
1. Medical professionals treating EVD state the family support or involvement, safe in-volvement, is a definite factor in improving recovery rates. The problem is however, that physi-cal contact is prohibited. The nearest approach usually tolerated is 7 feet.
I wondered whether it might not be feasible and effective to install remote viewing capa-bilities in ETUs? The family could communicate face to face with the patient lying in the ETU. The patient would have as intimate a contact with his family or better. It wouldn’t cost that much.
2. What about the use of Ebolabots to facilitate the care of EVD patients and to cut down on the high risk exposure for attending staff? Robots already available would be capable of de-livering food, cleaning up debris, and dealing with a lot of different situations. Some General motors robots I’ve seen on TV could probably start an IV line. I suspect there’s potential here for significant improvements in the treatment of EVD.
3. I’ll mention just one more imagining. Caring for an EVD patient, bathing them, looking after their needs is labor intensive and each event requires the exposure of staff to a high risk sit-uation. On an existing ETU room, one could build a small cylindrical attachment, looking sort of like an big iron lung.
The EVD patient in the ETU could be rolled into this attachment on a guerney. Inside the attachment, through plastic sleeves like in a nuclear plant, medical staff who remain outside the ETU could reach in, bathe the patient, feed them, change their clothers, and likely figure out how to obtain blood samples and start IV lines, all without having to suit up or enter the high risk en-vironment within the ETU. The iron lung room would be sprayed down with chloring when the patient is rolled back out. Then the next patient could be rolled in…
4. OK, one more. A plastic surrogate for the metallic sheets that are used to cover the ma-jority of roofs in Monrovia might be developed, and sold for a comparable price. The plastic panels would have efficient inbelt solar panel capability and this would put the entire country into a self sufficient mode with vast ramifications. It’s possible.
As the first week in Monrovia becomes history, I am filled with thankfulness for the ba-sics of life at home. You just don’t know what you’ve got until it’s gone, or not available. I wish
that every Liberian could just spend a few days with us at home, and see what a ‘normal’ life for us consists of. The elements I’d want to point out are the basic freedoms we depend on, the op-portunities we have to direct our lives, simple economic stability. While there are always excep-tions I’d rather be blue, thinking of you than be happy with somebody else…hmmm
The fact that I’m in Liberia on my own dollar, unconnected with any group or organiza-tion, seldom enters my consciousness. I can see the plethora of organizations at work in Liberia, many with shiny new four wheel drives with the air intakes stuck up high beside the passenger side window. I may be jeolous of their vehicles but I covet nothing else.
This morning however, James and I were talking as we drove. He was getting used to my sense of humor or not, and had asked me about a vehicle for use in Liberia. I said I’d like a flat bed Toyota with an M-60 mounted in the back.
He only looked shocked for a few seconds and then laughed. We continued driving down a busy, traffic clogged road. Then he asked me which organi-
zation I worked for. He must have been a bit puzzled by the ambiguity of my presence. As I said, everyone here who is not Liberian works for the UN, or USAID, or WHO or the Army. Not only that, but they tend to fill up the best hotels. At the MSF ETU the accommodations are Las Vegas class. They aren’t wanting in any department.
I suspect these things were going through Jame’s mind when he asked the question.
“I’m alone, James. I came here on my own. I don’t work for anybody else.” He looked over at me, a strange look on his face.
“Who pays for you to be here?”
“I pay for myself, nobody else is involved.”
“You are alone?!”
“Yup.” James thought this was the most hilarious thing he’d heard all day. He started laughing,
occasionally repeated “Alone!” and laughed so hard he almost drove us directly into the front end of an oncoming five ton truck. Swerving sharply out of the trucks path, he sobered up.“That was close,” he said unnecessarily.
“I may be alone, but I’m also alive, and I like it like that!” I added. That statement got James laughing again. I failed to see any humor in my situation, even within the context of being in Liberia.
LEAVING The decision to leave Liberia and return home was the right decision. I’d accomplished much of what I’d hoped to accomplish, though the anticipated answers to my questions didn’t exactly materialize. Leaving however, left me conflicted in a way that resisted deconfliction. I have to live with that.
PPRROOJJEECCTT EEBBOOLLAA 55..00
As the information gathered, the scientific studies that were published, all coalesced to produce answers to my questions, I no longer had a need to embark on an excursion into Guinea, Sierra Leone and Liberia, in search of still hidden answers. The writing was clearly on the wall.
The tremendous enthusiasm of my group at home, setting up a follow on project, was great. They are such an encouragement. I didn’t want to disappoint them after all their efforts, but the right decision was to pull the plug on Project Ebola 5.0.
SSKKIINNNNYY AASS BBEEAANNPPOOLLEESS
In the course of events in Liberia, I became familiar with a small group of young men who worked as security guys in Congo Town. When I met up with them from time to time, we’d shoot the breeze. One day as we were talking, the youngest man in the group quietly drew me aside, and with painful deference told me that they were quite hungry and had difficulty getting through the day as a result.
I sat down and asked a few questions. I discovered that most of them had families, that they received $75 salary per month, and that they had to sustain their lives under these condi-
tions. If they asked for a raise they’d be fired and some other eager man, from the pool of thou-sands available, would take their place. I realized to my chagrin that several times before I’d looked, but not really seen, how these skinny guys cinched their belts up, pulling it tight past the last hole, and then secured it by tying it into a knot on the side.
I gave the group $20 for food, and was embarrassed by their thanks. One of them quickly ran off to purchase something for the group. A native Liberian can be fairly frugal if they stick with country food, not the more processed western imports. These guys invested in rice and gra-vy.
I realize that I can’t solve all the problems in the world. But to not do what one can is not an option, not. During my stay in Monrovia I slipped my friends ten bucks or so a day. Not long before I left, I was chatting with them, and I saw that they had all opened up their belts, and were running on the second to last hole, or better. I don’t know what it’s like to have a baby, but I felt the same sense of accomplishment and pride arising from that observation.
Yes, when I left, the aid program stopped. But it is what it is…
EEBBOOLLAA
Almost unnoticed, the face of Ebola in Liberia slowly changed over the weeks. I was aware of the slow moving transition, the improvement in the epidemic stats, through the data presented at the IMS meetings. No one wanted to take the data at face value. The data could be quite unreliable and if the signs weren't 'real' disappointment was just too disappointing. Every-one longs for respite from the flames, and most of us cautiously let our hearts, if not leap for joy, at least skip a beat in anticipation that at all the signs that the ferociousness of the Ebola epidem-ic was being attenuated, that Ebola in Liberia was giving signs of beginning to improve, were real.
I became convince one day when I was standing on a market street in Monrovia, and real-ized that I'd been listening to... no sirens. The absence of the continuous wail of sirens in previ-ous weeks, was deafening. The evidence of absent things can be quite convincing: the dog that didn't back, the siren that didn't wail. The times they are a changing.
NNEEWW PPHHAASSEE OOFF EEPPIIDDEEMMIICC
By now almost a year had passed since the death of the purported index case, two-year-old Emile's. The official estimate of 5,500 deaths since, from Ebola, likely is less than half of the actual number of people who have died in less than a year.
Everything seemed to go wrong in the first months of the epidemic. Efforts to tackle Ebo-la have been hindered by fierce resistance from local communities with a history of suspicion towards any outside intervention. This enabled new chains of transmission to pop up and threat-en to spiral out of control.
Towards the end of October, a consensus was growing amongst the participants of the IMS meetings, that the Ebola epidemic was entering a new phase. This conclusion was based on the concordant trends observed in all the available field data. The question of the validity of the data gathered under the conditions present in Liberia remained, but everything was trending in a good way, indicating the face of Ebola was changing and implying that the response to Ebola should also change, to take advantage of the apparent progress.
Health officials openly suggested that the disease is now entering a new phase, with a marked slowing down in the some of the affected areas in the three countries, especially Guinea and Liberia.
WHO's Dr. Christopher Dye acknowledges. "Even if we are able to say the exponential phase is over, our goal is complete elimination in the human population and we clearly have a long way to go on that."
When Kevin De Cock flew home from this city of 1 million in August, he was leaving behind an apocalyptic scene. More than 100 people were coming down with Ebola daily. Patients were dying outside of treatment units filled to capacity, and bodies lay rotting in the streets. Some mathematical models projected that Liberia would face thousands of new cases weekly by December.
"There was really no way of knowing how much worse this might get," says De Cock, an
epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta. But when he returned to Monrovia on 9 November, the situation was very different. The grim projec-tions had been wrong. Although the Ebola epidemic is still growing in Sierra Leone, and Guin-ea's numbers are swinging up and down, Liberia is now reporting only about 20 new patients a day.
Treatment units have hundreds of empty beds, and Liberian President Ellen Johnson Sir-leaf has lifted the state of emergency put in place in August. Now the country faces new chal-lenges: rebuilding a shattered health care system, tamping down local outbreaks, and looking for ways to drive the number of new cases to zero.
No one here is quite sure what has caused the epidemic to wane. Safe burials may be a big factor, says Katri Jalava, a Finnish veterinarian and an epidemiological consultant to the World Health Organization. It's a local custom to wash the corpse and then use the same water to wash the hands of the bereaved, she says.
"In terms of a disease like Ebola that is absolutely mad." Most agree that people's every-day behavior has changed as well. Ubiquitous street signs warn that "Ebola is real" and tell Monrovians "Don't be the next case." Outside many homes are small hand-washing stations with bleach, and Liberians have stopped hugging and shaking hands.
Yet "this is still a catastrophe," De Cock says. Even 20 daily Ebola cases would have been unimaginable a year ago. And Guinea has shown that success in fighting Ebola can be short-lived: Twice, that country was on the cusp of ending the outbreak, and twice the virus came roaring back. Some have even questioned whether Liberia's recent drop in cases is real.
At a meeting at the Liberian ministry of health last week, a U.S. Agency for International Development representative said he had been sent specifically to find out if the numbers can be trusted. "Yes," answered Swedish statistician Hans Rosling, who has spent the past month in Monrovia helping the Liberian government interpret epidemiological data.
CDC researchers, for instance, have used mouth swabs to test dead bodies in Monrovia for Ebola; about 20% to 30% are now positive, down from close to 90% during the height of the ep-idemic. The real number of cases may be twice the reported number, but not much more, Rosling says. "We're in a new phase now."
The international response has been slow to adapt. Although the Pentagon has said it will build fewer new Ebola treatment centers, their construction is ongoing. "That doesn't make sense at all," says Thierry Goffeau, head of the Doctors Without Borders (MSF) mission in Liberia. "It's clearly a waste of human and financial resources."
Rosling, too, says tactics have to change. In September, the main job was building clinics, removing the dead, and keeping as many patients as possible isolated. Now, it's about setting up a flexible system to respond to new outbreaks, identifying patients quickly, and tracing their con-tacts to prevent more infections. "What we needed to do in the first phase was rugby," Rosling says. "Now it is chess."
Liberia's medical system, which collapsed under the weight of Ebola, is gearing up again. Doctors are returning to work, clinics are reopening. Goffeau says that is sorely needed: "People are dying at home of many other diseases than Ebola, because they have no access to health care." But medical staff still face an important risk. One in every hundred or thousand patients may carry the Ebola virus -- which could start new cycles of infection. There are reports that doctors at some clinics are now doing surgery and delivering babies in Ebola protection suits.
At Redemption Hospital in Monrovia, whose inpatient department was closed this summer after several doctors died from Ebola, MSF is trying to protect staff with a new triage unit, which opened on 19 November. Patients with Ebola-like symptoms are interviewed; if they meet the criteria for a suspect case, they stay in one of 10 small rooms while their blood is tested.
Those who test negative can enter the inpatient ward, while an ambulance takes Ebola pa-tients to a treatment unit. MSF has also started distributing malaria drugs to hundreds of thou-sands of people, not just to lower the burden of that disease, which was neglected for months, but also to reduce the number of people visiting hospitals with a fever.
Reopening Monrovia's schools poses similar quandaries. One idea is to screen pupils' temperature as they enter the school. "But what do you do if a 10-year-old kid has a high tem-perature and the other kids start pointing at him and shouting 'Ebola'?" Rosling says. In a meet-ing with President Sirleaf, he has argued for a cautious approach: opening some schools and carefully studying what happens.
The capital region still serves as a reservoir from which patients travel to rural areas and spark fresh outbreaks, De Cock says -- and now that the rainy season has ended, travel may pick up. In Bong County, for instance, a few hours northwest of Monrovia, two big outbreaks are spreading, at least one seeded from the capital. The treatment unit in the district of Suakoko, run by the International Medical Corps, is full, and new patients are brought in daily.
Sambhavi Cheemalapati, the unit's program coordinator, says she is seeing far more pa-tients than are accounted for in the official numbers. Aid should focus on spreading prevention messages in these remote locales, Goffeau says. "If the people really understand what Ebola is and how to avoid infection, we might stop this epidemic," he says.
Such regional flare-ups make it unlikely that the Liberian epidemic will be over anytime soon, Rosling says. Still, he believes it's possible that the country may see its first day without a single case as early as December. Given the cataclysmic projections of just 2 months ago, that would be a remarkable.
Sometimes you stumble across statistics that just scream at you. I was looking this week through some reports on the Liberian Ministry of Health's website. The screaming statistic was an "8" listed as the number of people "currently in treatment" at the ELWA 3 Ebola treatment unit run by Doctors Without Borders in Monrovia.
That couldn't possibly be right, I thought. ELWA 3 is the largest Ebola hospital ever built, with 250 beds. I was at the site when it was being built in August, and later when it was full. It's a massive complex, covering what used to be a huge empty field on the grounds of a missionary hospital. It's hard to get a sense of how big it is while you're walking amid the long white tents holding Ebola patients and suspected cases.
In August, ELWA3's size seemed depressing. The fact that such a large hospital was needed was an indication of how out of control the outbreak was. As the wards were being erect-ed behind her, Lindis Hurum, emergency coordinator for Doctors Without Borders in Monrovia, told me the outbreak was worsening every day.
"ELWA3 is going to be the biggest unit ever by MSF, and the reality is that we think that that will not be enough," she predicted.
At first it seemed she was right. ELWA3 opened originally with 120 beds, then quickly expanded to 250. In September it seemed that even that wasn't enough. Staff members had to turn away suspected Ebola patients at the gate. So to hear that the hospital's patient roster had dropped to just eight last week is great news.
A spokeswoman for Doctors Without Borders says the admissions fluctuate a lot, and the tally has since gone up from eight to 17. But still 17 Ebola patients is a far cry from 250. Part of why that statistic of eight screams so loudly is that ELWA3 is now a sign of how dramatically the number of cases has come down in Liberia. There's no denying that it was worth building the 250-bed hospital. It got all of those people out of circulation, so they couldn't spread the virus to others.
But now the international response once again seems out of step with epidemic. On the same day that ELWA3 had more than 200 empty beds last week, the Chinese government opened a brand new 100 bed Ebola treatment unit just down the street.
Large treatment centres being built in Liberia are standing empty, because the number of new infections of Ebola virus disease being reported there has dramatically fallen. Meanwhile, in Sierra Leone, where the epidemic continues to rise, hospitals are still turning patients away for lack of space, and a UK built treatment centre is not yet able to open all its beds because it is still recruiting and training staff.
In September, when the epidemic was at its peak in Liberia and patients in the capital, Monrovia, were dying in the streets for lack of beds, the United States announced plans to build 17 treatment centres of 100 beds in a ramping up of the international effort to stop the outbreak.
But three months later the US built centres that have opened are either empty or are now planning to use only 10 of their beds. The Chinese military also built a treatment centre on the edge of Monrovia, complete with air conditioning and digital record keeping systems, but by the time it opened on 24 November there were no new patients immediately needing treatment there.
"It takes states and some non-governmental organisations eight to 12 weeks to deploy," the international director of the charity Médecins Sans Frontières, Joanne Liu , told The BMJ. "Now they are arriving with a response that is tailored to yesterday's needs."
The treatment centres were planned as part of a multi-pronged approach that included promotion of safe burial practices and a communications effort that has reached 1.5 million of Liberia's 4.2 million population with leaflets, radio messages, and door to door meetings to build better understanding and teach people how to avoid catching the disease. The US believes that the effort led to the rapid decline of new cases in Liberia, where the total number of reported cases is now lower than in Sierra Leone, the latest World Health Organization figures show (7780 in Sierra Leone and 7719 in Liberia).
Today there is agreement that what is needed in Liberia is rapid response mobile units to reach remote areas quickly and treating patients and contact tracing when new cases are reported. The US is now diverting some resources to that while continuing to build 15 of the 17 planned treatment centres, with a view to using only 10 beds in each.
"We don't want to be in a situation where the disease goes dormant for a period and then explodes in a different part of the country and the capacity is not there to respond," said Matt Herrick, spokesman for the US Agency for International Development, which is coordinat-ing the US effort.
The US has spent $800m on its effort to fight Ebola virus disease, most of which has fo-cused on Liberia. It now has 28,000 government staff in Liberia, including 2600 military person-nel, but only 75 staff in Sierra Leone, which has a larger population (six million) and where the UK is leading the response and has committed $230m to a similar multi-pronged approach. There, a treatment centre built by the UK military on the edge of the capital, Freetown, and being run by Save the Children is not yet up to capacity, while government run hospitals are reportedly having to turn patients away.
"We're where Liberia was three weeks ago, not because we were complacent but just be-cause it didn't kick off as early as Liberia," Donal Brown, head of the UK Ebola Task Force, told the Washington Post recently. "We're not a month behind because we were sitting on our hands: we're a month behind because of the way the disease has played out."
The US is now planning a supportive role in Sierra Leone. "It's apparent we need to ex-pand our response across west Africa," said Herrick.
SSEELLFF AASSSSEESSSSMMEENNTT
I am confident in the validity of conclusions reached on the etiology of this epidemic, and on the factors extrinsic to the Ebola virus itself, that made this such a deadly, destructive and tragic epidemic. I'm less confident that the knowledge we now have of what steps need to be tak-en -- establishment of health care centers, testing centers in the field, surveillance and alert sys-tems, will translate into bricks and mortar on the ground. If it doesn't, there will be an Ebola 5.0, and it very well may go on tour, show the developed world what it's learned in the previous dec-ade hidden in the jungles of central Africa.
But if the world, for once, will keep it's act together, and put in place the surveillance and alerting systems we know are necessary, there may never again be an Ebola outbreak which claims more than 20 victims.
THOUGHTS ON LEAVING COMPLETE THIS SEGMENT
Time came to return. Acute care opportunities I had no funds to support myself. Understood what I hadn't before. The solution to preventing 5.0 already existed. It wasn't
a secret waiting to be disclosed. We know how to do it but will we. International involvement key, and worthy self interest.
1. Elements necessary to preventing a recurrence of en Ebola mandemic, exist Kept a journal but didn't look at this trip as much as a personal adventure but more as an
exploration of the untoward factors underlying what might have been a pandemic. Extant surveil-lance systems, other essentials for preventing Ebola 5.0, exist. They obviously failed and the rea-sons for these failures needs to be determined and corrected.
Treatment for Ebola virus infection needs to be realized.
Vaccines for prevention need to be developed. Leaving Liberia felt like being raised on a rope from a deep, scary well, rising slowly to-
wards the sunlight, wracked with guilt at the knowledge that simply by an accident of birth, I was able to leave, while many other vital human beings, their families their children, their hopes and dreams, remained helplessly in the killing grounds, doomed to a degree by a vast concatena-tion of dark forces that are almost impossible to overcome. For anyone to overcome.
If I was a Liberian kid, perhaps a child warrior who'd had his legs shot off, scrambling or-phan trying to scrounge up a buck a day just to eat, no prospects of education, of a job, of sympa-thetic help from anyone, how long would it be before I'd throw in the towel.
Perhaps one aspect of the Old Masters that I'd overlooked before, was that it may at times be easier to live if we are ignorant of our true circumstances, if just the Old Master's are aware of our plight caught in the jaws of life, leaving us with some hope, meaningless as it is in fact. This knowledge is more acute than it has ever been for myself, from my first trips overseas, when the great discrepancy between the living conditions of much of the world and my living conditions, first ate it's way through my consciousness and began a festering painful coexistence with me.
In practical terms, it's true, there is virtually nothing I as an individual can do to make all this better. Communications, economics and inter-relationships might do the trick in a century or two.
Leaving a sawbuck anywhere in Monrovia, wouldn't even go look for it. I know that who ever would find it, would put it to much better use than I ever could. There would be no waste, no frivolous expenditure of my sawbuck. It would go into food. No one smoked. Some drinking though...
This kind of knowledge can leave one depressed, as it sits like a cloud over every daily ac-tivity, you know it, even though those around you are unaware that as they enjoy the afternoon picnic in the park, that millions of humans, just a Skype away, are being driven into the mud of human existence without a whisper of a chance of escaping.
Corruption is especially onerous in such situations.
Chronic violence, often fed by weapons coming from our countries Of course one doesn't stop doing what's possible. Gave alot of money away in Liberia, to
the beggars, the amputees, and so on. Couldn't have done any harm but I always felt the accurate sting of my knowledge that this dollar bill is not going to help you tomorrow when everything working against your having a simple human life with some potential, will once again flood over you.
Bribes, education, jobs, wars, ins cuties, disease... The tragedy of this Ebola outbreak and all the sadness, loss of life, disruption of entire
countries, is the result of the incompetence of the World Health Organization. Trusted by most nations with efficient response to infectious disease outbreaks, the current organization so totally failed in it's mandate, that thousands of deaths now hang like a sign of negligence around it's neck. There should be an accounting, but there won't be.
WWAASS TTHHEE JJOOUURRNNEEYY WWOORRTTHH IITT??
Yes, most certainly. This was a journey who's effects will remain with me for the rest of my life. No matter how much further I'm privileged to ride Voyager 1, the vision of west Africa will always be visible.
During my absence in west Africa, Voyager 1 travelled sped another 37,000,000 miles further from earth. Reimagining myself back on the satellite on my return, although the planet earth remained invisible to my naked eye, I could clearly hear the laughter of some street kids in Monrovia, kicking around a plastic soccer ball I bought for them on a hot Ebola afternoon, long ago.
I can't forecast the trajectory that the Ebola epidemic of 2014 will follow. At the time of this writing, Ebola is infecting more human beings in west Africa. Despite signs the epidemic is receding, the potential threat to humans from this global menace should still make our hearts beat faster.
I hope that over the next six months or less, the number of new cases will continue to drop, and the number of geographic locations where new cases develop, also continues to de-cline. If so, we can expect that in a few months, someone will announce that the 2014 Ebola epi-
demic has finally been quenched. The damages incurred, measured in human terms, material terms, psychological terms, is disproportionately greater than might be estimated simply on the basis of the number of fatalities. I hope that after the final bell sounds, that the world will then get down to work on building up the systems necessary to prevent this from ever again occur-ring.
My conclusion after visiting Liberia, reviewing the literature, pursuing answers to key questions of my own devising, is that Ebola will always be with us. Also, the anomalous features of the 2014 epidemic are explainable as the consequences of a major failure of medical intelli-gence. The epidemic's overall evolution is not a function of a virus that's altered it's modus op-erandi, but it's a product of the failure of men and human institutions to do the right thing, the known thing.
Above: Rains in Sierra Leone. There is a season for all things.
In a memorandum written for WHO in 1980, Dr. Simpson spelled out the essentials of dealing with Ebola. The essentials have not changed since then. What has not happened howev-er, is the establishment by the global community working with regional governments, of Ebola proof surveillance, alerting and interdiction systems, such as Dr. Simpson recommended decades ago. My hopes for the future are based on an unverifiable trust that people with the organization-al expertise will be able to command the cooperation of governments and marshall the necessary resources to built an anti-Ebola defensive system into the fabric of central Africa. The necessary instructions are in Dr. Simpson's memorandum.
Thankfully, the present epidemic, in it's few moves outside of Africa, nonetheless scared the bejeebies out of most of the world which I believe now sees that it's in thei own interests to cooperate together and with the central African governments to do what we know is necessary to have an Ebola free world.
[Right now, Ebola free world to me means that the recurring outbreaks of Ebola will never again claim more than 5 victims before being snuffed out by a global hammer blow. Perhaps with the advent of effective vaccines, the world will in effect become Ebola free. I'm not holding my breath though. Some self-trained expert will certainly announce that anti-Ebola vaccines are a plot by Americans to take over the world and in addition, the vaccine causes the recipients to vote Independent.]
The people I've met, the information I've received or read, suggests to me that the world has actually learned a lesson this time. The excellent, wide spread media coverage, exceptional in my opinion, likely has a major role in bringing this transformation about. Thank you technol-ogy, thank you reporters and photographers, and thank you scientists.
OK, where were we? Oh yes... I'd almost completed an outline of Chaper Six when Ebola arrived. Assuming that the diversion is now at an end, I'll continue on to work on Chapter 8. If I have my way, and I should have it as I'm the one writing this, Chapter 8 is the final chapter. Ac-tually, it's only the final Chapter of the introduction to the MorningStar account, which I haven't written yet. This has become a spooky, never ending book. If I'd have known about this when I was younger, I'd never have learned so many adjectives
APRIL 2015 WHO EPIDEMIC DATA The latest data, published by WHO on 20 April, show that there has been a
TOTAL: 25 863 cases
TOTAL: 10 715 deaths.
The primary reason for this epidemic which threatened the entire globe, was lax surveil-lance systems, inadequate resources and the failure of humans in UN agencies to act
promptly to the signs from the field.
Dr. Matthew's Passion By Blaine Harden Published: February 18, 2001 In the last few hours before he died, Simon Ajok seemed to explode -- first in
blood, then in aggravation. The burly male nurse, who had contracted Ebola while caring for patients in an
isolation ward at St. Mary's Hospital in northern Uganda, was wearing an oxygen mask when he started to hemorrhage. The oxygen had turned his blood bright red. It saturated the whites of his eyes and swelled his eyelids to near-bursting. He began to bleed profusely from his nose and gums. Fighting to breathe, Simon ripped off his oxygen mask. He coughed violently, spraying a fine mist of mucous and blood onto the wall beside his bed.
Then, to the astonishment and terror of the night-shift staff in the Ebola ward, the 32-year-old nurse hauled himself out of bed. Coughing blood and muttering angrily, he lurched out of his private room and into the long hallway of the ward. Simon had pulled loose from his catheter. An IV tube dangled from his arm.
Babu Washington Stanley was a nurse on duty that night. As he would later recall, he and others on the ward retreated down the corridor while he shouted, ''Please, Simon, go back!'' They were covered head to toe in protective gear -- rubber boots, gowns, aprons, gloves, masks, head caps and plastic eye shields. But they had never seen a critically ill Ebola patient behave like this.
Biomedical researchers admit profound ignorance about Ebola, a viral bleeding fever that first appeared in Africa in the late 1970's. There is no cure, and researchers do not know where the virus hides between human outbreaks. They do know, though, that the blood of an acutely ill Ebola patient is one of the most infectious and deadly substances on earth.
The Ebola epidemic that broke out last fall in Uganda and lasted until January was the largest ever. More than 400 people were infected; 173 died. But the patients there, even those who died, did not suffer the massive and uncontrollable bleeding from nearly every orifice that has made Ebola the dark star of the world's infectious diseases. That is, until the night Simon Ajok erupted.
''Please, Simon, go back!'' Babu Washington Stanley shouted again that night, as his wildly agitated colleague stood bleeding in the hallway.
Not knowing what else to do, the nurse did what everyone at the 500-bed hospital had done for years, whenever things got out of control. At 5 a.m. on Nov. 20, he called Dr. Matthew Lukwiya.
Dr. Matthew, as he was known to his colleagues and patients, was the hospital's
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Dr. Matthew's Passion
medical superintendent. He had helped make it one of the best medical facilities in East Africa. He was also a home-grown hero in the scrub savanna of northern Uganda.
Children playing in the dust-blown streets of Gulu, a city a few miles from St. Mary's Hospital, had for years been singing a little ditty about the doctor. In it, they dared each other to jump from a high place. A broken leg would not be a problem, they sang; Dr. Matthew would fix it.
In his 17 years at St. Mary's, a Catholic missionary hospital, much of what Dr. Matthew fixed had nothing to do with medicine. A soft-spoken, deeply religious man of 42, with a wide, easy smile and a slight paunch, he had stood up to a bizarre bunch of local rebels called the Lord's Resistance Army. They said they wanted to run Uganda according to the Ten Commandments. But what they had done for 13 years was kidnap thousands of children and press them into suicidal duty as soldiers. The rebels also abducted and mutilated adults, often slicing off their lips and ears.
When rebels came to the hospital in 1989 to kidnap some Italian nuns living there, Dr. Matthew (who was an evangelical Protestant, not a Catholic) met them at the front gate and persuaded them to take him instead. He marched around in the bush for a week in his doctor's gown before the rebels let him go. He later opened the walled compound at St. Mary's as a sanctuary from the rebels. Until Ebola scared them away, about 9,000 people entered the grounds of St. Mary's every evening to sleep in peace.
The panicked call from Nurse Stanley roused Dr. Matthew from his bed. His small house was located inside the hospital compound, and the doctor made it to the Ebola isolation ward within five minutes. He suited up, as always, in boots, gown, apron, head cap, gloves and mask. He neglected, however, to put on goggles or a plastic face shield, which can protect the eyes when an Ebola patient coughs. Perhaps he was still groggy from sleep.
Simon Ajok had by then stumbled back to bed, where he was gasping for breath in his private room (one of the meager privileges afforded health- care workers who caught Ebola at St. Mary's). To help him breathe, Dr. Matthew pulled Simon, who was sticky with blood, into a sitting position. He then cleaned him up, stripping off his soaked gown and changing the soggy sheets on his bed. Simon died while the doctor was mopping the floor with bleach.
When he finished cleaning up, Dr. Matthew went back to his house, ate some breakfast and then put in another 14-hour day.
A few days after Simon died, Dr. Matthew reviewed the events of that night with Dr. Piero Corti, an Italian missionary who, along with his wife, Dr. Lucille Teasdale, founded St. Mary's Hospital in 1961 and ran it for decades. Dr. Matthew
was his chosen successor. The more Dr. Corti listened, the more furious he became. He was exasperated
by the gamble his protege had taken. ''I wanted to strangle him,'' said Dr. Corti, who is 75. ''I was thinking of the
future and that he was the man to take care of the hospital for the next 20 or 30 years. But I didn't have the heart to tell him that. He had done what was normal for him to do.''What was normal for Dr. Matthew was a low-key combination of geniality and unyielding resolve. He flatly refused to allow anyone or anything, be it messianic rebels or bleeding fevers, to destroy his hospital. To that end, he sometimes took chances that threatened his life, that bordered on recklessness. Yet he was such a solid medical man, such a devout Christian and such a nice guy that hardly anyone noticed his extraordinary appetite for risk.
For Dr. Matthew, the first hint of an Ebola outbreak in Uganda came on Saturday morning, Oct. 7, when the telephone rang in his rented house in Kampala. At the time, he was temporarily living in the capital in order to finish up a master's degree in public health. After nearly a decade of running a hospital in the middle of a civil war, he and his wife, Margaret, along with their five children, decamped from the north in December 1998 and moved to Kampala.
''There seems to be a strange disease killing our student nurses,'' said the caller. It was Dr. Cyprian Opira, who was phoning long-distance from St. Mary's Hospital, where he was acting medical superintendent.
The strange illness, Dr. Opira said, had stumped everyone. The usual antibiotics did nothing. Stool cultures were not informative. A student nurse began bleeding from the mouth just as she died.
''We need your presence,'' Dr. Opira said on the phone. Temporary escape from this kind of all-consuming responsibility had been a
precious fringe benefit of Dr. Matthew's leave of absence from St. Mary's. He had taken the leave to study at Kampala's Makerere University, telling his colleagues he would come back a better manager.
His wife rejoiced in the move. Kampala was 250 miles and a world away from the troubles of Gulu District and the endless responsibility of the hospital. For starters, there was no incoming artillery. At St. Mary's, a year before the move to Kampala, a mortar shell bounced off a tree and punched through the roof of Dr. Matthew's house in the hospital compound. It crashed on the floor -- without exploding -- not far from the bed where he and Margaret were sleeping.
War was traumatizing the children, Dr. Matthew told his wife, who couldn't have agreed more. The move to Kampala also gave the doctor and his wife a vacation from
the demands of his being a very big man in a very poor corner of Africa. Gulu District, which borders Sudan, is part of Acholi land, a semiarid region of
goats, cows and subsistence farms long neglected by the government of President Yoweri Museveni. Electricity, for example, is turned off in Gulu on weekends, and it often goes off during the week.
In the tribal calculus that shapes politics and patronage in Uganda and across Africa, the Acholi people are viewed by Museveni's government as suspect. Museveni came to power in 1986 after waging a long guerrilla war against an Acholi-dominated regime. During that war, Acholi soldiers murdered tens of thousands of Ugandans as part of a savage cycle of tribal killing that began in the 1970's under Idi Amin, probably Africa's most famous practitioner of brutal one-man rule. Museveni put an end to the killing and led Uganda into an era of rebuilding and relative prosperity. But Acholi land was largely left behind.
The lack of development and government services in Gulu District has been filled, in part, by successful Acholi men like Dr. Matthew. His extended family, his clan and his tribe all made constant demands on his income, his influence and his kitchen. At their home in the hospital compound, Margaret usually cooked for about 20 people at each meal; eight sat at the dining-room table, five sat in the kitchen and seven or so camped in the living room. Dr. Matthew paid school fees for the children of many of his relatives. They came to him when they were sick. And if they died, he often paid to transport their bodies back to their home villages for burial.
The move to Kampala limited the importuning of the kinfolk. Margaret remembers their 22 months together in the Ugandan capital as the sweetest season of their married life. Dr. Matthew loved being back in school, she said. It gave him a chance to study the latest techniques for managing the care of patients whose troubles ranged from poor hygiene to gunshot wounds to AIDS.
School had always been his salvation. He had grown up poor in the northern town of Kitgum, about an hour's drive from St. Mary's, with no strong kinship ties to the Acholi oligarchy in the Ugandan military. His father was a fishmonger who drowned when he was 12. His mother was a petty trader. She fed her four sons by smuggling Ugandan tea on her bicycle across the border to Sudan, where she traded for soap. She trained Matthew to be a bicycling smuggler, but it was in the classroom where he paid close attention. He was a phenomenal student, a permanent fixture at the top of his class in grade school, secondary school, university and medical school.
With a long string of scholarships as his rope, he pulled himself up from the lowest social rung in one of Uganda's poorest regions to academic acclaim in the capital. Then he immediately returned to Acholi land.
When Matthew first showed up at St. Mary's as an intern in 1983, Dr. Corti, the Italian missionary, remembers that he and Lucille, a surgeon at the hospital, were amazed by the young doctor's intelligence and gentle ability to lead. ''God sent that man here,'' Dr. Corti said. ''Within three months of his arrival, I told my wife that he is the one who can take over. She smiled and said she was thinking the same thing. People say we groomed him to run the hospital. He groomed himself.''
Dr. Matthew left Uganda for a year in 1990 to take a master's degree in tropical pediatrics at the Liverpool School of Tropical Medicine. As usual, he graduated first in his class. Dr. Bernard Brabin, who supervised his degree, said that of all the hundreds of young doctors from around the world whom he has taught in the past decade, Dr. Matthew was one of the most impressive.
''First, it was a matter of ability,'' Dr. Brabin said. ''He had a highly critical intelligence that adapted very quickly to complexity. He expressed himself in clear, simple ways. We encouraged him to stay in the United Kingdom, to teach and pursue higher degrees. But his commitment was to the care of children in Uganda.''
Unlike tens of thousands of African professionals who leave the continent for better pay and better lives abroad, Dr. Matthew apparently never even considered such a move. In letters he wrote from Liverpool to Dr. Corti at St. Mary's, he said not to worry about the hospital's future; he would be back. Even if he was to get another advanced degree, he vowed, he would come back and do his research at St. Mary's.
''Have you ever heard of a missionary temperament?'' asked Dr. Brian Coulter, a senior lecturer at the Liverpool School who knew Dr. Matthew well and who visited him at St. Mary's several times in the 1990's. ''That is exactly what Matthew had. His aim in life was to minister to sick children and to run one of the few institutions that function efficiently in Uganda. That is what satisfied him, and that is what he wanted.''
While studying for his second master's degree in Kampala, Dr. Matthew insisted that his children take education as seriously as he did. He read to his twin 9-year-old boys every night, Margaret said, and he pestered his son, Peter, 12, to work harder on math. For the first time in his life, he also had time to relax with his children, to follow British soccer on the BBC and to get a bit thicker around the middle.
All this came to an end, however, when the telephone rang and Dr. Matthew heard the words ''strange disease.'' He left for the north at once, arriving at St. Mary's Hospital in the early evening, in time to witness the death of a nursing student named Daniel Ayella. As the nurse died, the whites of his eyes turned red, and blood dribbled from his mouth. Dr. Matthew had never seen anything like it.
''We thought it was something beyond our knowledge,'' said Dr. Yoti Zabulon, who stood beside Dr. Matthew that night and watched the nurse die. ''We needed help.''
The following day, a Sunday, Dr. Matthew told Sister Maria Di Santo, head of nursing at St. Mary's, that he wanted to see the charts on all patients who had died strangely in recent weeks. He began drawing a map of suspicious deaths. It included 17 patients, two of them student nurses. Another student nurse was also gravely ill and would soon die.
That afternoon, community leaders from Gulu District came to the hospital. They told Dr. Matthew that whole families were dying in their villages. They demanded something be done. Dr. Matthew and Sister Maria stayed up most of that night, reviewing charts and comparing symptoms with C.D.C. and World Health Organization publications on infectious fevers that cause bleeding. Their suspicion and fear, Sister Maria said, was that it was Ebola. But they had never before treated or seen patients with the disease.
What they read was based largely on what doctors had learned from the last major Ebola outbreak in Kikwit, Congo, in 1995, where 318 people got sick and 4 out of 5 of them died. The literature explained that close physical contact, especially unprotected exposure to an infected person's body fluids, caused most new infections. The publications also explained that the sicker a patient becomes, the more dangerously infectious he or she is. Touching dead bodies, the literature said, was a major risk.
As Dr. Matthew well knew, the dead-body factor was especially alarming in Acholi land, where tradition demands that female relatives of the deceased work together to wash and dress a corpse. After a body has been buried, those in the funeral party wash their hands together in a common basin, joined by other mourners from the village. The tradition symbolizes solidarity, but during an Ebola epidemic it was a recipe for catastrophe.
''By morning it became obvious to Dr. Matthew that it was some kind of hemorrhagic fever in our hospital,'' Dr. Zabulon said. ''He said, 'Let's go around the usual bureaucracy and call Kampala.' ''
The call was taken by Dr. Sam Okware, Uganda's commissioner of community health services, who dispatched a team to Gulu from the Uganda Virus Research Institute. When they arrived to collect blood samples, Dr. Matthew had already begun to move suspected Ebola patients into an isolation ward that he had set up following W.H.O. guidelines.
Sub-Saharan Africa is widely viewed as incapable of dealing with epidemics --
for example, AIDS. In countries like South Africa and Zimbabwe, where a fifth to a quarter of the adult population is infected, AIDS will kill around half of all 15-year-olds, according to the United Nations. Around the world there are 16 countries where H.I.V.-prevalence rates exceed 10 percent. All 16 are in Africa.
Uganda, however, happens to be a can-do kind of place when it comes to public health disasters. It dropped off the United Nations list of countries most affected by AIDS because its government was the first in Africa to launch a substantial awareness campaign. It distributed millions of free condoms and relentlessly explained how H.I.V. is transmitted by sexual contact. The campaign is credited with lowering the infection rate to 8 percent, from 14 percent in the early 1990's.
''Transparency, openness and modern communications, that is what we use,'' said Dr. Okware, the former head of Uganda's AIDS control program who was quickly named chairman of its National Ebola Task Force.
When lab tests confirmed Ebola, the Ministry of Health contacted the W.H.O., the C.D.C. and major donor nations and called a news conference. It hired more than a thousand ''local informants'' in 346 villages in Gulu District. They went from hut to hut, looking for sick people, who often were hidden by their families. Ebola burial teams were trained and outfitted with protective clothing. In parts of the district where the Lord's Resistance Army is active, the army dispatched armored personnel carriers to search for the sick and collect bodies. Ebola alerts filled the newspapers and state radio.
''All dead bodies should be immediately buried in sacks made of polyethylene materials,'' said one typically blunt public-service announcement in a Kampala daily.
The campaign worked, but it also caused some panic. According to Dr. Okware, rural people burned villages where Ebola was rumored to be. Officials in neighboring Tanzania and Kenya seemed to suspect that all Ugandans carried Ebola, screening them at the borders and sending hundreds home. Saudi Arabia banned Ugandans from the hajj. Even the Lord's Resistance Army blinked, releasing 40 abductees it feared were infected.
Across northern Uganda, there was panic buying of Jik, a brand of household bleach manufactured in Kenya. Ebola burial teams used the stuff to soak sickbeds, douse bodies and sterilize themselves after a burial. As a result, some rural Ugandans worshiped Jik as a ''miracle drug,'' according to Dr. Paul Onek, director of health services in Gulu District. He said they kept a bottle around the hut as a talisman to scare off Ebola. People bathed in bleach and some drank it.
''I have heard that some of you are drinking Jik to stop infection right from the stomach,'' Ronald Reagan Okumu, a member of Parliament from Gulu, said at a news
conference on Oct. 30. ''Nobody should drink Jik.'' That same day, several hundred Acholi traditionalists took matters into their
own hands in Gulu town. They tried to chase out the virus by shouting, running around with spears and beating on saucepans. They told Ugandan journalists they intended to exorcise the evil of Ebola and send it south toward Kampala.
The patient load at St. Mary's soared in the week after Ebola was confirmed. By the third week of October, with the number of patients approaching 60, the three doctors, five nurses and five nursing assistants who had volunteered to work on the isolation ward were overwhelmed.
They could not handle the load, in part, because of the time and personal attention that they gave to each Ebola patient. In other African hospitals, the treatment strategy was entirely different. Doctors encouraged a spouse or family member to be the primary caregiver for each patient. Wearing protective clothing, caregivers cooked for and cleaned up after their loved ones. The system reduced risks for nurses and nursing assistants, keeping them away from infectious body fluids.
Dr. Matthew, however, kept all kin away from infectious patients. He allowed only doctors, nurses and nursing assistants to go near them. His system helped contain the epidemic, reducing sickness and mortality rates among family members. At the same time, though, it placed health-care workers in close quarters with highly infectious patients and increased their chances of contracting Ebola. Whether it was against rebels or viruses, Dr. Matthew made a habit of taking personal risks for the sake of his hospital. In a pleasant but dogged way, he insisted that his nurses do likewise.
''There is no right answer to the question of how to nurse Ebola patients in Africa,'' said Dr. Daniel Bausch, a C.D.C. medical epidemiologist who worked in northern Uganda last fall and managed the Ebola ward at a small government hospital in Gulu town. In many African hospitals, it is less a matter of best medical opinion than of what is possible. Dr. Bausch used family caregivers on the Ebola ward at Gulu Hospital because he said he had no reasonable alternative. St. Mary's, though, had the facilities and the personnel to take on the care and feeding of Ebola patients without family help.
Whatever its medical or epidemiological value, Dr. Matthew's system became a management nightmare. He tried to reassure nurses and nursing assistants that the risk was tolerable. Yet as the weeks went by, Ebola insidiously eroded his authority. Health-care workers wore their protective gear, they managed their risks and still they got sick. Twelve of them died.
''With each death, the tension built,'' said Sister Maria. ''You could feel the atmosphere. It was building toward a climax. There were so many questions and no answers.''
To keep his volunteer nurses from bolting, Dr. Matthew tried to lead by example. He was in the Ebola ward every morning at 7 and he finished up around 8 in the evening. As he made his rounds, he preached caution.
''Think with your head, not with your heart,'' he shouted at one nurse in late October, when she rushed to clean up after a patient who had vomited on the floor. Dr. Matthew instructed the nurse to douse the vomit with bleach before going near the patient.
In the evenings after leaving the isolation ward, Dr. Matthew visited the many foreign doctors who had set up laboratories and were helping to care for patients at St. Mary's, as well as at nearby Gulu Hospital. As they ate their dinner in the compound of his hospital, he questioned them about patient care, searching for ways to keep his nurses from getting sick. Dr. Bausch, the C.D.C. medical epidemiologist who joined in these chats nearly every night for two months, said no one could give Dr. Matthew a satisfactory reason why the nurses were getting infected.
''Very few of these nurses had ever been in a situation where they had to put on gowns, gloves, masks and wash their hands after every contact with every patient,'' said Dr. Bausch. ''Dr. Matthew was in a situation where he had no choice but to herd around inexperienced people who didn't want to be there.''
The pressure on him was unending. But Dr. Bausch said that through it all Dr. Matthew was ''a very kind, very mild-mannered guy who liked to make jokes,'' especially about the endless American presidential election. ''He didn't seem as stressed as a lot of people would have been.''
Privately, Dr. Matthew was afraid -- for himself and for the hospital. He did not want his wife or his children to come near him. On Oct. 14, he wrote to Margaret in Kampala: ''I will not be able to come to you there because we are very busy, and secondly because it would be dangerous to you, in case I am incubating the disease, although it is very unlikely. You should not also come here! The situation is very bad.''
The situation in the hospital became a whole lot worse in late November. By then, the national Ebola epidemic had peaked, and the number of new cases was beginning to fall. Not so for patients and nurses inside St. Mary's.
During a 24-hour period that ended at dawn on Nov. 24, seven people died of Ebola, including three health-care workers. Two of these workers were nurses who did not work in the Ebola ward. By breakfast, news of their deaths was causing panic. If nurses who stayed away from the isolation ward could die, it seemed that anyone
could die. Nurses mutinied. The day-shift staff did not show up for work. Instead, at 8:45 a.m., about 400 health-care workers, nearly the entire staff at St. Mary's, packed into the assembly hall of the hospital's nursing school.
''We were very many and we were so scared and we were a bit aggressive somehow,'' said Margaret Owot, a nurse who attended the meeting and who worked on the Ebola ward. ''Ebola was a disease that no one knows how it is killing, and the nurses thought everybody would die.''
When Dr. Matthew heard about the meeting, he rushed to the assembly hall and demanded to know what it was that the nurses wanted. ''We are thinking that the hospital should be closed,'' one nurse shouted.
By this time, Dr. Matthew was well versed in the art of persuading frightened health-care workers to swallow their fear. He had made a series of inspirational speeches at staff meetings and funerals. At the largest of those funerals, for an Italian nun who died of Ebola, he had spoken on Nov. 7 of the responsibilities of love.
''It is our vocation to save life,'' he said then, in a talk recorded by the Rev. Matthew Odong, the vicar general of the Catholic archdiocese of Gulu and Dr. Matthew's longtime friend. ''It involves risk, but when we serve with love, that is when the risk does not matter so much. When we believe our mission is to save lives, we have got to do our work.''
But on the morning of the mutiny, which happened to be his birthday, Dr. Matthew apparently concluded that inspirational rhetoric would not keep the hospital open. So he used threats. ''If the hospital is closed, I will leave and I will never come back to Gulu,'' he said, according to Owot.
He had their attention. With the assembly hall stone silent, Dr. Matthew told the nurses, most of whom
he had helped train, the story of how he had volunteered to be kidnapped by the Lord's Resistance Army. He had been afraid the rebels would kill him, but he took the risk to protect the hospital and keep it open for patients who had no place else to go.
The kidnapping tale laid out the principles that governed his life and the circumstances under which he was willing to risk losing it. By telling the story, he challenged the nurses to live, and perhaps to die, by the values that had brought them into nursing in the first place.
If you abandon the hospital because of fear, he concluded, many patients will die, and you will be responsible.
''For me, I felt that he gave us really a fatherly word,'' said Owot, a nurse who has worked at St. Mary's for 16 years. ''He made me see that if the hospital is closed and I fall sick, where would I go? Who would nurse me?''
At another long and contentious staff meeting in the same hall that afternoon, Dr. Matthew shifted back to inspiration, which was much more his style. He could not force them to stay, he said, but he would continue fighting Ebola, alone if necessary, until the virus was beaten or until he was dead.
He joined the nurses in a song. The mutiny was over. That evening, his wife called him, and all his children came on the line to sing
''Happy Birthday.'' But Dr. Matthew was exhausted. ''Margaret, I cannot talk,'' he told her. ''I need to rest.''
A total of 29 health-care workers contracted Ebola in Uganda, and 17 of them died, according to the C.D.C. Exactly how any of them got infected is not known with a high degree of certainty. But there is a consensus among doctors who worked in Uganda, as well as in Congo during previous Ebola outbreaks, about how the infection is not spread.
Simply breathing in the vicinity of people who are infected with Ebola is unlikely to make you sick. Ebola is not a ''free virus'' that floats around for hours in the air of an isolation ward. ''There has to be a real line of transmission,'' Dr. Bausch said. That means direct contact with body fluids, like vomit, blood or sweat. But the experts agree that a coughing patient who is spraying mucous or blood into the air is also a threat.
''It is not known if this spray landing on bare skin is enough,'' said Simon Mardel, a W.H.O. consultant who often made rounds with Dr. Matthew. ''It seems most likely that there has to be a break in the skin. When a patient coughs, a much more likely route of inoculation for a health-care worker is the mouth, the nose or the eyes.''
Experts guess that many of the health-care workers who got sick in Uganda made a small mistake. Their protective clothing, in the equatorial heat, may have made them uncomfortable or claustrophobic. After touching a patient, they may have gotten careless and slipped a gloved finger inside their protective mask to scratch an itchy nose or rub a sweaty eye.
Almost none of the health-care workers in Uganda wore goggles at all times inside the isolation wards. They quickly fogged up. As a result, a nurse couldn't find a vein for a blood sample. A doctor couldn't see a patient's face or read a chart.
''I would have my goggles on, but if I got close to a patient to listen to his lungs, I would put my goggles down,'' said Dr. Bausch, who makes his living by working around the world's most infectious viruses and describes himself as ''incredibly careful.''
During the epidemic in Uganda, complaints about foggy goggles resulted in
shipments of, among other things, plastic face shields that look like upside-down hockey masks. They did not fog up like goggles, but they were far from perfect. Open at the top, they left room for particles of coughed blood to drift down into the eyes.
Like most of the doctors and nurses, Dr. Matthew did not always wear eye protection. Babu Washington Stanley, the night-shift nurse who called him out of bed on Nov. 20, the night Simon Ajok erupted in blood, clearly remembers that the doctor did not put on goggles or a plastic face shield that night.
Although no one can be sure, this lapse may have been what infected Dr. Matthew. In his rush to help a dying nurse whom he had helped train, he violated his own rules. He thought with his heart.
Two days after his birthday, on a Sunday Night, Dr. Matthew called his wife. She was startled by the sound of his voice. He was heavily congested and coughing.
''Margaret,'' he said, ''I have a terrible flu.'' Monday morning he had a fever. At the hospital infirmary, he told Sister Maria
he had malaria. She agreed it must be malaria. ''We said malaria, but we thought Ebola,'' Sister Maria said.
The fever grew worse as the day went by. He canceled meetings and went home to bed. By Tuesday, antimalarial drugs had not brought down his fever. By Wednesday morning, he was vomiting, and he found it difficult to keep liquids down. Dr. Pierre Rollin from the C.D.C. ran blood tests. They were done at a lab on the hospital compound.
That night, Grace Obuu, 24, who became a nurse at St. Mary's after Dr. Matthew and his wife adopted her, went to his house. He was alone, and she put him on an IV drip to help keep him hydrated. His fever was high, and he was very weak, the nurse said, but he had stopped vomiting. She was startled by the sound of his voice. He was speaking loudly and distinctly, and he was not talking to her.
''Oh, God, I think I will die in my service,'' he prayed. ''If I die, let me be the last.'' Then, in a powerful voice, he sang ''Onward Christian Soldier.''
Two years earlier in a Pentecostal church in Kampala, Dr. Matthew had delighted his born-again wife by raising his hand and announcing to the congregation that he, too, was born again. Always a churchgoing Protestant, he had since been going to church twice a week, until the ''strange disease'' called him away from Kampala.
The blood test came back positive for Ebola. ''When I told him, he himself asked to go to the isolation ward,'' Dr. Rollin said.
''He said, 'Since I am the boss, I should show an example.' '' A telephone call was finally placed on Thursday afternoon to Margaret, who had
heard nothing since Sunday night. Dr. Matthew had not wanted her called, saying he
feared that she would take the call on her mobile phone while driving in traffic and would get in a wreck.
She was sitting on a sofa at home when the phone rang. She immediately packed her bag, hired a taxi and left for Gulu. But she was late reaching an upcountry bridge across the Nile River. Soldiers block it at night as a security measure against the Lord's Resistance Army. Margaret had to sleep in the taxi.
On Friday morning at 9:30, dressed in protective gear, including goggles, she approached her husband's bedside. He was in Room 4 in the Ebola ward, next to the room where Simon Ajok died 11 days earlier. At the sight of him, Margaret began to cry, and she rushed toward his bed to hug him.
''Don't you come close to me!'' Dr. Matthew warned. ''You will get infected.'' He called a doctor, who brought Margaret a stool. She sat about three feet
away. ''You can't stay here when you are crying,'' he told his wife. ''You will get
infected. You don't have to cry. You have to be strong and only pray.'' She stopped crying. He asked her how the children were doing in school. He was
particularly worried, she said, that Peter was not paying proper attention to math. After about 15 minutes, he seemed tired, and she left. That evening, he was
stronger, as Margaret remembers, and his eyes were clear. He said that he probably got Ebola from Simon Ajok, and he struggled to explain why he took the risks that made him ill.
''Look, Margaret, it is a rough time, I know,'' he said. His wife recalled his words with reverent precision, as if she were reciting from Scripture. ''You were not expecting this. God's will is not our will. I did not also expect to get, you know, infected. But being a person working in the foreground in this place, anything can happen. A mechanic can get his hands chopped off in a machine. Even a woman when she is cooking can get burned. So you just have to accept the situation.''
Margaret became angry. ''Now I can't even touch you,'' she told him. ''I can't even nurse you. I can't do anything. I just have to sit aside like a traitor.''
''You have to accept your fate,'' he replied. ''I don't want you to get infected. If anything happens to me, at least you will be alive to look after my children.''
On Saturday, his breathing was worse. He found it difficult to speak. Ignoring his warnings, Margaret moved close enough to touch her husband through the four surgical gloves she wore on each hand. During her 20-minute visits, she held his foot.
Dr. Matthew was getting weaker by the hour, exhausting himself as he fought for breath. On Sunday afternoon his doctors asked Margaret's permission to put him on a respirator. She gave permission, but before the machine was hooked up, she went
to his bedside and asked him to pray with her. ''I said, 'Be strong, fight this sickness with the blood of Jesus,' '' Margaret
said. He complained that he was dry and, until the doctors shooed her away to hook up
the respirator, she slipped ice cubes into his mouth with her gloved fingers. The breathing machine seemed to be the answer. When Margaret left her
husband's bedside early Monday evening, his fever had come down, the oxygen level in his blood had risen and his pulse was near normal. One doctor told her it was a miracle. Late Monday night, however, his lungs hemorrhaged. This was the worst-case scenario his doctors had feared, and they could do nothing.
Dr. Matthew died at 1:20 a.m. on Dec. 5. By the time Margaret was notified and ran to the Ebola ward, he had been zipped up in a polyethylene body bag. She asked that it be unzipped just a little so she could see his face for the last time. The corpse, she was told, was too infectious. The answer
Doctors who treat Ebola are not convinced that they have a whole lot to offer any patient. They estimate that using IV drips to replace lost fluids might make a difference for about 10 percent of those who get sick. For others, they guess, the seriousness of the illness depends on the genetic makeup of a patient, the amount of tainted blood or other body fluid that has come in contact with a patient and the route of infection. The prick of a bloody syringe, for example, is almost certainly worse than a cough in the face.
It also depends on the strain of the virus. In Congo in 1995, about 80 percent of those infected with Ebola died. But the strain of the virus that the C.D.C. isolated in northern Uganda was different from what they found in Congo and considerably less deadly.
It was identical to a strain that caused two Ebola outbreaks in nearby southern Sudan in the late 1970's. There, in a place where medical care was all but nonexistent, the death rate was around 50 percent -- roughly the same as it was last year in the best Ugandan hospitals. The numbers suggest that modern medicine, at least so far, is helpless to change the rate at which the various strains of Ebola kill human beings.
''Ebola is a tough disease,'' Dr. Bausch said. ''I am not so sure that once someone is infected that the treatment we offer prevents more people from dying than would have died anyhow. The saddest example of that is Dr. Matthew. When he got sick, people pulled out all the stops. But it didn't matter.''
Ebola is also finicky, depending on who gets infected. The same viral strain, acquired in the same way on the same evening, from the same infectious patient, can
kill one person, while giving another a headache. Babu Washington Stanley, the night-shift nurse, also got sick with Ebola nine days after he and Dr. Matthew struggled to care for Simon Ajok. Stanley, though, came down with the mildest case of Ebola on record in Uganda. He had a headache for a few days, and then it went away. Ebola made him hungry, he said, especially for liver. Now he is fine.
There is an amateur videotape of Dr. Matthew's burial. It is almost unbearable to watch.
According to a will he wrote in the Ebola ward in the days before his death, a grave was chosen inside the hospital compound beneath a towering banyan tree. It lay beside the grave of Lucille Teasdale, the surgeon who was the wife of Dr. Corti. Dr. Teasdale, who died of AIDS she contracted while operating on patients at St. Mary's, had been Dr. Matthew's mentor, champion and great friend.
Since his body was highly infectious, he was buried the day he died. An Ebola burial team, dressed in protective gear that seemed suitable for a lunar landing, rolled up to the grave site at 4 p.m. in a white ambulance. They whisked a simple wooden coffin out of the ambulance and lowered it into the grave with ropes. All the while, one member of the burial team sprayed the coffin, the ropes and his colleagues with Jik bleach. More a disposal procedure than a burial, it was over in less than five minutes.
On the videotape, at the moment the ambulance comes into view, the soundtrack explodes with the screaming of nurses. Earsplitting and inconsolable, in voices that fused grief, exhaustion and rage, their shrieking was the hopeless music of the funeral. The nurses were part of a crowd of several hundred people who had been warned to stay well away from the grave until it was covered with dirt.
Margaret stood at a distance with her children. She had insisted that they witness the burial. Otherwise, she believed it would be impossible for them to accept their father's death. They arrived from Kampala just 30 minutes before the service.
Many government officials, including the minister of health, had also rushed north to Gulu. During the height of the Ebola epidemic last fall, Dr. Matthew had been quoted almost daily in the Ugandan press. He had become a national icon: the fearless field commander at the center of a biological war that threatened everyone in the country. Even though the Ebola outbreak had been all but defeated by the time he died, Dr. Matthew's death rattled the country's self-confidence, suggesting somehow that the center could not hold.
For a time, the doctor's death paralyzed Uganda's fight against what was left of the Ebola epidemic. St. Mary's Hospital stopped admitting new Ebola patients. Across Gulu District, a number of health-care workers quit. Suspected Ebola patients
refused to be taken to hospitals. According to Dr. Onek, the health officer for Gulu District, local people were asking, ''Why go to the hospital, if the big doctor has died in the hospital?''
Six weeks after the funeral, during a long and mournful conversation about the consequences of Dr. Matthew's death, Sister Maria said St. Mary's had not yet recovered, and she doubted that it ever would. The hospital has not been able to find a new medical superintendent.
''You know, so many people relied on him,'' she said. ''He had clear ideas about what to do with the future of the hospital. We have lost a guide. He was so clever in a way of talking to you kindly. He could lead people. That is what we have lost.''
Margaret, too, felt lost. President Museveni praised her husband's courage and promised her about $2,800 as a special death benefit. But that would not be nearly enough, Margaret said, to finish building a house in Kampala or to send five children to university, as her husband had planned. She said she did not know how she would be able to honor his wishes.
The doctor who made the mistake of thinking with his heart left far more behind than a vacuum.
Epidemiologists who traveled to Gulu credit Dr. Matthew with helping to contain Ebola before it could spread. His insistence on immediately calling senior health officials in Kampala jump-started the government's public-awareness campaign. He may have saved hundreds, perhaps thousands, of lives.
As important for containing future outbreaks, C.D.C. virologists said his support for their research means that Uganda's epidemic should produce more scientific data on Ebola than all the other outbreaks in Africa combined.
''If you need it, you have it,'' Dr. Matthew told foreign researchers when they descended on Uganda, according to Dr. Rollin.
Access to St. Mary's laboratories allowed researchers to preserve a vast number of blood samples from Ebola patients at every stage of infection.
The samples could help them discover how Ebola triggers a cascade of immunological events that turn the body's defenses against itself, transforming white blood cells into subversive agents that trigger bleeding. The samples could also help them understand -- and perhaps one day invent a drug to inspire -- the remarkable immune response that allowed Babu Washington Stanley to shake off Ebola as if it were a mild hangover.
Father Odong, the vicar general of Gulu, said that he hoped his friend's story will offer his fellow Africans a new definition of what it means to be a big man in Africa. ''It is not about getting rich and having power,'' he said. ''We should tell
everyone the story of Dr. Matthew.'' Whether or not his story survives, its last chapter did turn out as Dr. Matthew
had hoped. His hospital and his nation defeated Ebola, at least this time around. With no
new cases in the previous 21 days, W.H.O. declared on Feb. 6 that the epidemic was effectively over. The isolation ward at St. Mary's has been closed and scrubbed down and will reopen this month as a children's ward. And Dr. Matthew's solitary prayer in the week before he died was answered: among the health-care workers who fought Ebola at St. Mary's, he was the last to die.
Blaine Harden is a reporter for The Times. His last article for the magazine was about the collapse of Kenya's tourist economy.
Dr. Matthew's Passion When the Ebola virus hit Uganda's remote Gulu District, there was only one man
to call for help. By BLAINE HARDEN n the last few hours before he died, Simon Ajok seemed to explode -- first in blood, then in aggravation. The burly male nurse, who had contracted Ebola while caring for patients in an isolation ward at St. Mary's Hospital in northern Uganda, was wearing an oxygen mask when he started to hemorrhage. The oxygen had turned his blood bright red. It saturated the whites of his eyes and swelled his eyelids to near-bursting. He began to bleed profusely from his nose and gums. Fighting to breathe, Simon ripped off his oxygen mask. He coughed violently, spraying a fine mist of mucous and blood onto
the wall beside his bed. Then, to the astonishment and terror of the night-shift staff in the Ebola ward,
the 32-year-old nurse hauled himself out of bed. Coughing blood and muttering angrily, he lurched out of his private room and into the long hallway of the ward. Simon had pulled loose from his catheter. An IV tube dangled from his arm.
Babu Washington Stanley was a nurse on duty that night. As he would later recall, he and others on the ward retreated down the corridor while he shouted, "Please, Simon, go back!" They were covered head to toe in protective gear -- rubber boots, gowns, aprons, gloves, masks, head caps and plastic eye shields. But they had never seen a critically ill Ebola patient behave like this.
Ebola's Path: Dr. Matthew, a modern medical savior. Photograph by Kennedy Oryema/New Vision.
Blaine Harden is a reporter for The Times. His last article for the magazine was about the collapse of Kenya's tourist economy.
Biomedical researchers admit profound ignorance about Ebola, a viral bleeding fever that first appeared in Africa in the late 1970's. There is no cure, and researchers do not know where the virus hides between human outbreaks. They do
know, though, that the blood of an acutely ill Ebola patient is one of the most infectious and deadly substances on earth.
The Ebola epidemic that broke out last fall in Uganda and lasted until January was the largest ever. More than 400 people were infected; 173 died. But the patients there, even those who died, did not suffer the massive and uncontrollable bleeding from nearly every orifice that has made Ebola the dark star of the world's infectious diseases. That is, until the night Simon Ajok erupted.
"Please, Simon, go back!" Babu Washington Stanley shouted again that night, as his wildly agitated colleague stood bleeding in the hallway.
Not knowing what else to do, the nurse did what everyone at the 500- bed hospital had done for years, whenever things got out of control. At 5 a.m. on Nov. 20, he called Dr. Matthew Lukwiya.
r. Matthew, as he was known to his colleagues and patients, was the hospital's medical superintendent. He had helped make it one of the best
medical facilities in East Africa. He was also a home- grown hero in the scrub savanna of northern Uganda.
Children playing in the dust-blown streets of Gulu, a city a few miles from St. Mary's Hospital, had for years been singing a little ditty about the doctor. In it, they dared each other to jump from a high place. A broken leg would not be a problem, they sang; Dr. Matthew
'With each death, thetensionbuilt,' Sister Maria said. ' . . . It was building toward a climax. There were so many questions and no answers.'
would fix it. Inhis17yearsatSt.Mary's,aCatholic missionary hospital, much of what Dr.
Matthew fixed had nothing to do with medicine. A soft-spoken, deeply religious man of 42, with a wide, easy smile and a slight paunch, he had stood up to a bizarre bunch of local rebels called the Lord's Resistance Army. They said they wanted to run Uganda according to the Ten Commandments. But what they had done
for 13 years was kidnap thousands of children and press them into suicidal duty as soldiers. The rebels also abducted and mutilated adults, often slicing off their lips and ears.
When rebels came to the hospital in 1989 to kidnap some Italian nuns living there, Dr. Matthew (who was an evangelical Protestant, not a Catholic) met them at the front gate and persuaded them to take him instead. He marched around in the bush for a week in his doctor's gown before the rebels let him go. He later opened the walled compound at St. Mary's as a sanctuary from the rebels. Until Ebola scared them away, about 9,000 people entered the grounds of St. Mary's every evening to sleep in peace.
he panicked call from Nurse Stanley roused Dr. Matthew from his bed. His small house was located inside the hospital compound, and the
doctor made it to the Ebola isolation ward within five minutes. He suited up, as always, in boots, gown, apron, head cap, gloves and mask. He neglected, however, to put on goggles or a plastic face shield, which can protect the eyes when an Ebola patient
coughs. Perhaps he was still groggy from sleep. Simon Ajok had by then stumbled back to bed, where he was gasping for breath in his private room (one of the meager privileges afforded health-care workers who caught Ebola at St. Mary's). To help him breathe, Dr.
Matthew pulled Simon, who was sticky with blood, into a sitting position. He then cleaned him up, stripping off his soaked gown and
changing the soggy sheets on his bed. Simon died while the doctor was mopping the floor with bleach.
When he finished cleaning up, Dr. Matthew went back to his house, ate some breakfast and then put in another 14-hour day.
A few days after Simon died, Dr. Matthew reviewed the events of that night with Dr. Piero Corti, an Italian missionary who, along with his wife, Dr. Lucille Teasdale, founded St. Mary's Hospital in 1961 and ran it for decades. Dr. Matthew was his chosen successor.
The more Dr. Corti listened, the more furious he became. He was exasperated by the gamble his protege had taken.
"I wanted to strangle him," said Dr. Corti, who is 75. "I was thinking of the future and that he was the man to take care of the hospital for the next 20 or 30 years. But I didn't have the heart to tell him that. He had done what was normal for him to do."
What was normal for Dr. Matthew was a low-key combination of geniality and unyielding resolve. He flatly refused to allow anyone or anything, be it messianic rebels or bleeding fevers, to destroy his hospital. To that end, he sometimes took chances that threatened his life, that bordered on recklessness. Yet he was such a solid medical man, such a devout Christian and such a nice guy that hardly anyone noticed his extraordinary appetite for risk.
or Dr. Matthew, the first hint of an Ebola outbreak in Uganda came on Saturday morning, Oct. 7, when the telephone rang in his rented house
in Kampala. At the time, he was temporarily living in the capital in order to finish up a master's degree in public health. After nearly a decade of running a hospital in the middle of a civil war, he and his wife, Margaret, along with their five children, decamped from the north in December 1998 and moved to Kampala.
"There seems to be a strange disease killing our student nurses," said the caller. It was Dr. Cyprian Opira, who was phoning long-distance
An Ebola ward at a Gulu hospital; Simon Ajok, the nurse whose case was fatal, and not just for him. Photograph by Jodi Bieber/Network Photographers/SABA. For The New York Times.
from St. Mary's Hospital, where he was acting medical superintendent.
The strange illness, Dr. Opira said, had stumped everyone. The usual antibiotics did nothing. Stool cultures were not informative. A student nurse began bleeding from the mouth just as she died.
"We need your presence," Dr. Opira said on the phone. Temporary escape from this kind of all-consuming responsibility had been a
precious fringe benefit of Dr. Matthew's leave of absence from St. Mary's. He had taken the leave to study at Kampala's Makerere University, telling his colleagues he would come back a better manager.
His wife rejoiced in the move. Kampala was 250 miles and a world away from the troubles of Gulu District and the endless responsibility of the hospital. For starters, there was no incoming artillery. At St. Mary's, a year before the move to Kampala, a mortar shell bounced off a tree and punched through the roof of Dr. Matthew's house in the hospital compound. It crashed on the floor -- without exploding -- not far from the bed where he and Margaret were sleeping.
War was traumatizing the children, Dr. Matthew told his wife, who couldn't have agreed more. The move to Kampala also gave the doctor and his wife a vacation from the demands of his being a very big man in a very poor corner of Africa.
Gulu District, which borders Sudan, is part of Acholi land, a semiarid region of goats, cows and subsistence farms long neglected by the government of President Yoweri Museveni. Electricity, for example, is turned off in Gulu on weekends, and it often goes off during the week.
In the tribal calculus that shapes politics and patronage in Uganda and across Africa, the Acholi people are viewed by Museveni's government as suspect. Museveni came to power in 1986 after waging a long guerrilla war against an Acholi-dominated regime. During that war, Acholi soldiers murdered tens of thousands of Ugandans as part of a savage cycle of tribal killing that began in
the 1970's under Idi Amin, probably Africa's most famous practitioner of brutal one-man rule. Museveni put an end to the killing and led Uganda into an era of rebuilding and relative
Simon Ajok, the nurse whose case was fatal, and not just for him. prosperity. But Acholi land was largely left behind. The lack of development and government services in Gulu District has been
filled, in part, by successful Acholi men like Dr. Matthew. His extended family, his clan and his tribe all made constant demands on his income, his influence and his kitchen. At their home in the hospital compound, Margaret usually cooked for about 20 people at each meal; eight sat at the dining-room table, five sat in the kitchen and seven or so camped in the living room. Dr. Matthew paid school fees for the children of many of his relatives. They came to him when they were sick. And if they died, he often paid to transport their bodies back to their home villages for burial.
The move to Kampala limited the importuning of the kinfolk. Margaret remembers their 22 months together in the Ugandan capital as the sweetest season of their married life. Dr. Matthew loved being back in school, she said. It gave him a chance to study the latest techniques for managing the care of patients whose troubles ranged from poor hygiene to gunshot wounds to AIDS.
School had always been his salvation. He had grown up poor in the northern town of Kitgum, about an hour's drive from St. Mary's, with no strong kinship ties to the Acholi oligarchy in the Ugandan military. His father was a fishmonger who drowned when he was 12. His mother was a petty trader. She fed her four sons by smuggling Ugandan tea on her bicycle across the border to Sudan, where she traded for soap. She trained Matthew to be a bicycling smuggler, but it was in the classroom where he paid close attention. He was a phenomenal student, a permanent fixture at the top of his class in grade school, secondary school, university and medical school.
With a long string of scholarships as his rope, he pulled himself up from the lowest social rung in one of Uganda's poorest regions to academic acclaim in the capital. Then he immediately returned to Acholi land.
When Matthew first showed up at St. Mary's as an intern in 1983, Dr. Corti, the Italian missionary, remembers that he and Lucille, a surgeon at the hospital, were amazed by the young doctor's intelligence and gentle ability to lead. "God sent that man here," Dr. Corti said. "Within three months of his arrival, I told my wife that he is the one who can take over. She smiled and said she was thinking the same thing. People say we groomed him to run the hospital. He groomed himself."
Dr. Matthew left Uganda for a year in 1990 to take a master's degree in tropical pediatrics at the Liverpool School of Tropical Medicine. As usual, he graduated first in his class. Dr. Bernard Brabin, who supervised his degree, said that of all the hundreds of young doctors from around the world whom he has taught in the past decade, Dr. Matthew was one of the most impressive.
"First, it was a matter of ability," Dr. Brabin said. "He had a highly critical intelligence that adapted very quickly to complexity. He expressed himself in clear, simple ways. We encouraged him to stay
in the United Kingdom, to teach and pursue higher degrees. But his commitment was to the care of children in Uganda."
Unlike tens of thousands of African professionals who leave the continent for better pay and better lives abroad, Dr. Matthew apparently never even considered such a move. In letters he wrote from Liverpool to Dr. Corti at St. Mary's, he said not to worry about the hospital's future; he would be back. Even if he was to get another advanced degree, he vowed, he would come back and do his research at St. Mary's.
"Have you ever heard of a missionary temperament?" asked Dr. Brian Coulter, a senior lecturer at the Liverpool School who knew Dr. Matthew well and who visited him at St. Mary's several times in the 1990's. "That is exactly what Matthew had. His aim in life was to minister to sick children and to run one of the few institutions that function efficiently in Uganda. That is what satisfied him, and that is what he wanted."
While studying for his second master's degree in Kampala, Dr. Matthew insisted that his children take education as seriously as he did. He read to his twin 9-year-old boys every night, Margaret said, and he pestered his son, Peter, 12, to work harder on math. For the first time in his life, he also had time to relax with his children, to follow British soccer on the BBC and to get a bit thicker around the middle.
All this came to an end, however, when the telephone rang and Dr. Matthew heard the words "strange disease." He left for the north at once, arriving at St. Mary's Hospital in the early evening, in time to witness the death of a nursing student named Daniel Ayella. As the nurse died, the whites of his eyes turned red, and blood dribbled from his mouth. Dr. Matthew had never seen anything like it.
"We thought it was something beyond our knowledge," said Dr. Yoti Zabulon, who stood beside Dr. Matthew that night and watched the nurse die. "We needed help."
he following day, a Sunday, Dr. Matthew told Sister Maria Di Santo, head of nursing at St. Mary's, that he wanted to see the charts on all
patients who had died strangely in recent weeks. He began drawing a map of suspicious deaths. It included 17 patients, two of them student nurses. Another student nurse was also gravely ill and would soon die.
That afternoon, community leaders from Gulu District came to the hospital. They told Dr. Matthew that whole families were dying in their villages. They demanded something be done.
Dr. Matthew and Sister Maria stayed up most of that night, reviewing charts and comparing symptoms with C.D.C. and World Health Organization publications on infectious fevers that cause bleeding. Their suspicion and fear, Sister Maria said, was that it was Ebola. But they had never before treated or seen patients with the disease. What they read was based largely on what doctors had learned from the last
major Ebola outbreak in Kikwit, Congo, in 1995, where 318 people got sick and 4 out of 5 of them died. The literature explained that close physical contact, especially unprotected exposure to an infected person's body fluids, caused most new infections. The publications also explained that the sicker a patient becomes, the more dangerously infectious he or she is. Touching dead bodies, the literature said, was a major risk.
As Dr. Matthew well knew, the dead-body factor was especially alarming in Acholi land, where tradition demands that female relatives of the deceased work together to wash and dress a corpse. After a body has been buried, those in the funeral party wash their hands together in a common basin, joined by other mourners from the village. The tradition symbolizes solidarity, but during an Ebola epidemic it was a recipe for catastrophe.
"By morning it became obvious to Dr. Matthew that it was some kind of hemorrhagic fever in our hospital," Dr. Zabulon said. "He said, 'Let's go around the usual bureaucracy and call Kampala.' "
The call was taken by Dr. Sam Okware, Uganda's commissioner of community health services, who dispatched a team to Gulu from the Uganda Virus Research
Institute. When they arrived to collect blood samples, Dr. Matthew had already begun to move suspected Ebola patients into an isolation ward that he had set up following W.H.O. guidelines.
Sub-Saharan Africa is widely viewed as incapable of dealing with epidemics -- for example, AIDS. In countries like South Africa and Zimbabwe, where a fifth to a quarter of the adult population is infected, AIDS will kill around half of all 15-year-olds, according to the United Nations. Around the world there are 16 countries where H.I.V.-prevalence rates exceed 10 percent. All 16 are in Africa.
Before going to an Ebola ward, a Gulu woman is disinfected, probably with Jik, a bleach that many Ugandans treated like a miracle drug. Photograph by Dennis Ojwee/New Vision.
Uganda, however, happens to be a can-do kind of place when it comes to public health disasters. It dropped off the United Nations list of
countries most affected by AIDS because its government was the first in Africa to launch a substantial awareness campaign. It distributed millions of free condoms and relentlessly explained how H.I.V. is transmitted by sexual contact. The campaign is credited with lowering the infection rate to 8 percent, from 14 percent in the early 1990's.
"Transparency, openness and modern communications, that is what we use," said Dr. Okware, the former head of Uganda's AIDS control program who was quickly named chairman of its National Ebola Task Force.
When lab tests confirmed Ebola, the Ministry of Health contacted the W.H.O., the C.D.C. and major donor nations and called a news conference. It hired more than a thousand "local informants" in 346 villages in Gulu District. They went from hut to hut, looking for sick people, who often were hidden by their families. Ebola burial teams were trained and outfitted with protective clothing. In parts of the district where the Lord's Resistance Army is active, the army dispatched armored personnel carriers to search for the sick and collect bodies. Ebola alerts filled the newspapers and state radio.
"All dead bodies should be immediately buried in sacks made of polyethylene materials," said one typically blunt public-service announcement in a Kampala daily.
The campaign worked, but it also caused some panic. According to Dr. Okware, rural people burned villages where Ebola was rumored to
be. Officials in neighboring Tanzania and Kenya seemed to suspect that all Ugandans carried Ebola, screening them at the borders and sending hundreds home. Saudi Arabia banned Ugandans from the hajj. Even the Lord's Resistance Army blinked, releasing 40 abductees it feared were infected. Across northern Uganda, there was panic buying of Jik, a brand of household
bleach manufactured in Kenya. Ebola burial teams used the stuff to soak sickbeds, douse bodies and sterilize themselves after a burial. As a result, some rural Ugandans worshiped Jik as a "miracle drug," according to Dr. Paul Onek, director of health services in Gulu District. He said they kept a bottle around the hut as a talisman to scare off Ebola. People bathed in bleach and some drank it.
"I have heard that some of you are drinking Jik to stop infection right from the stomach," Ronald Reagan Okumu, a member of Parliament from Gulu, said at a news conference on Oct. 30. "Nobody should
As the epidemic raged at St. Mary's, Dr. Matthew insisted that his wife, Margaret (with picture), and family not visit him. Photograph by Tyler Hicks for The New York Times.
drink Jik." That same day, several hundred Acholi traditionalists took matters into their
own hands in Gulu town. They tried to chase out the virus by shouting, running around with spears and beating on saucepans. They told Ugandan journalists they intended to exorcise the evil of Ebola and send it south toward Kampala.
he patient load at St. Mary's soared in the week after Ebola was confirmed. By the third week of October, with the number of patients
approaching 60, the three doctors, five nurses and five nursing assistants who had volunteered to work on the isolation ward were overwhelmed.
They could not handle the load, in part, because of the time and personal attention that they gave to each Ebola patient. In other African hospitals, the treatment strategy was entirely different. Doctors encouraged a spouse or family member to be the primary caregiver for each patient. Wearing protective clothing, caregivers cooked for and cleaned up after their loved ones. The system reduced
risks for nurses and nursing assistants, keeping them away from infectious body fluids.
Dr. Matthew, however, kept all kin away from infectious patients. He allowed only doctors, nurses and nursing assistants to go near them. His system helped contain the epidemic, reducing sickness and mortality rates among family members. At the same time, though, it placed health-care workers in close quarters with highly infectious patients and increased their chances of contracting Ebola. Whether it was against rebels or viruses, Dr. Matthew made a habit of taking personal risks for the sake of his hospital. In a pleasant but dogged way, he insisted that his nurses do likewise.
"There is no right answer to the question of how to nurse Ebola patients in Africa," said Dr. Daniel Bausch, a C.D.C. medical epidemiologist who worked in northern Uganda last fall and managed the Ebola ward at a small government hospital in Gulu town. In many African hospitals, it is less a matter of best medical opinion than of what is possible. Dr. Bausch used family caregivers on the Ebola ward at Gulu Hospital because he said he had no reasonable alternative. St. Mary's, though, had the facilities and the personnel to take on the care and feeding of Ebola patients without family help.
Whatever its medical or epidemiological value, Dr. Matthew's system became a management nightmare. He tried to reassure nurses and nursing assistants that the risk was tolerable. Yet as the weeks went by, Ebola insidiously eroded his authority. Health-care workers wore their protective gear, they managed their risks and still they got sick. Twelve of them died.
"With each death, the tension built," said Sister Maria. "You could feel the atmosphere. It was building toward a climax. There were so many questions and no answers."
To keep his volunteer nurses from bolting, Dr. Matthew tried to lead by example. He was in the Ebola ward every morning at 7 and he finished up
around 8 in the evening. As he made his rounds, he preached caution. "Think with your head, not with your heart," he shouted at one nurse in late
October, when she rushed to clean up after a patient who had vomited on the floor. Dr. Matthew instructed the nurse to douse the vomit with bleach before going near the patient.
In the evenings after leaving the isolation ward, Dr. Matthew visited the many foreign doctors who had set up laboratories and were helping to care for patients at St. Mary's, as well as at nearby Gulu Hospital. As they ate their dinner in the compound of his hospital, he questioned them about patient care, searching for ways
to keep his nurses from getting sick. Dr. Bausch, the C.D.C. medical epidemiologist who joined in these chats nearly every night for two months, said no one could give Dr. Matthew a satisfactory reason why the nurses were getting infected.
"Very few of these nurses had ever been in a situation where they had to put on gowns, gloves, masks and wash their hands after every contact with every patient," said Dr. Bausch. "Dr. Matthew was in a situation where he had no choice but to herd around inexperienced people who didn't want to be there."
The pressure on him was unending. But Dr. Bausch said that through it all Dr. Matthew was "a very kind, very mild-mannered guy who liked to make jokes," especially about the endless American presidential election. "He didn't seem as stressed as a lot of people would have been."
Privately, Dr. Matthew was afraid -- for himself and for the hospital. He did not want his wife or his children to come near him. On Oct. 14, he wrote to Margaret in Kampala: "I will not be able to come to you there because we are very busy, and secondly because it would be dangerous to you, in case I am incubating the disease, although it is very unlikely. You should not also come here! The situation is very bad."
he situation in the hospital became a whole lot worse in late November. By then, the national Ebola epidemic had peaked, and the number of
new cases was beginning to fall. Not so for patients and nurses inside St. Mary's. During a 24-hour period that ended at dawn on Nov. 24, seven people died of
Ebola, including three health-care workers. Two of these workers were nurses who did not work in the Ebola ward. By breakfast, news of their deaths was causing panic. If nurses who stayed away from the isolation ward could die, it seemed that anyone could die. Nurses mutinied. The day-shift staff did not show up for work. Instead, at 8:45 a.m., about 400 health-care workers, nearly the entire staff at St. Mary's, packed into the assembly hall of the hospital's nursing school.
"We were very many and we were so scared and we were a bit aggressive somehow," said Margaret Owot, a nurse who attended the meeting
and who worked on the Ebola ward. "Ebola was a disease that no one knows how it is killing, and the nurses thought everybody would die."
When Dr. Matthew heard about the meeting, he rushed to the assembly hall and demanded to know what it was that the nurses wanted.
"We are thinking that the hospital should be closed," one nurse shouted. By this time, Dr. Matthew was well versed in the art of persuading frightened
health-care workers to swallow their fear. He had made a series of inspirational speeches at staff meetings and funerals. At the largest of those funerals, for an Italian nun who died of Ebola, he had spoken on Nov. 7 of the responsibilities of love.
"It is our vocation to save life," he said then, in a talk recorded by the Rev. Matthew Odong, the vicar general of the Catholic archdiocese of Gulu and Dr. Matthew's longtime friend. "It involves risk, but when we serve with love, that is when the risk does not matter so much. When we believe our mission is to save lives, we have got to do our work."
But on the morning of the mutiny, which happened to be his birthday, Dr. Matthew apparently concluded that inspirational rhetoric would not keep the hospital open. So he used threats. "If the hospital is closed, I will leave and I will never come back to Gulu," he said, according to Owot.
He had their attention. With the assembly hall stone silent, Dr. Matthew told the nurses, most of whom
he had helped train, the story of how he had volunteered to be kidnapped by the Lord's Resistance Army. He had been afraid the rebels would kill him, but he took the risk to protect the hospital and keep it open for patients who had no place else to go.
The kidnapping tale laid out the principles that governed his life and the circumstances under which he was willing to risk losing it. By telling the story, he challenged the nurses to live, and perhaps to die, by the values that had brought them into nursing in the first place.
If you abandon the hospital because of fear, he concluded, many patients will die, and you will be responsible.
"For me, I felt that he gave us really a fatherly word," said Owot, a nurse who has worked at St. Mary's for 16 years. "He made me see that if the hospital is closed and I fall sick, where would I go? Who would nurse me?"
At another long and contentious staff meeting in the same hall that afternoon, Dr. Matthew shifted back to inspiration, which was much more his style. He could not force them to stay, he said, but he would continue fighting Ebola, alone if necessary, until the virus was beaten
or until he was dead. He joined the nurses in a song. The mutiny was over. That evening, his wife called him, and all his children came on the line to sing
"Happy Birthday." But Dr. Matthew was exhausted. "Margaret, I cannot talk," he told her. "I need to rest."
total of 29 health-care workers contracted Ebola in Uganda, and 17 of them died, according to the C.D.C. Exactly how any of them got infected is
not known with a high degree of certainty. But there is a consensus among doctors who worked in Uganda, as well as in Congo during previous Ebola outbreaks, about how the infection is not spread.
Simply breathing in the vicinity of people who are infected with Ebola is unlikely to make you sick. Ebola is not a "free virus" that floats around for hours in the air of an isolation ward. "There has to be a real line of transmission," Dr. Bausch said. That means direct contact with body fluids, like vomit, blood or sweat. But the experts agree that a coughing patient who is spraying mucous or blood into the air is also a threat.
"It is not known if this spray landing on bare skin is enough," said Simon Mardel, a W.H.O. consultant who often made rounds with Dr. Matthew. "It seems most likely that there has to be a break in the skin. When a patient coughs, a much more likely route of inoculation for a health-care worker is the mouth, the nose or the eyes."
Experts guess that many of the health-care workers who got sick in Uganda made a small mistake. Their protective clothing, in the equatorial heat, may have made them uncomfortable or claustrophobic. After touching a patient, they may have gotten careless and slipped a gloved finger inside their protective mask to scratch an itchy nose or rub a sweaty eye.
Almost none of the health-care workers in Uganda wore goggles at all times inside the isolation wards. They quickly fogged up. As a result, a nurse couldn't find a vein for a blood sample. A doctor couldn't see a patient's face or read a chart.
"I would have my goggles on, but if I got close to a patient to listen to his lungs, I would put my goggles down," said Dr. Bausch, who makes his living by working around the world's most infectious viruses and describes himself as "incredibly careful."
During the epidemic in Uganda, complaints about foggy goggles resulted in shipments of, among other things, plastic face shields that look like upside-down hockey masks. They did not fog up like goggles, but they were far from perfect. Open at the top, they left room for particles of coughed blood to drift down into the eyes.
Like most of the doctors and nurses, Dr. Matthew did not always wear eye protection. Babu Washington Stanley, the night-shift nurse who called him out of bed on Nov. 20, the night Simon Ajok erupted
in blood, clearly remembers that the doctor did not put on goggles or a plastic face shield that night.
Although no one can be sure, this lapse may have been what infected Dr. Matthew. In his rush to help a dying nurse whom he had helped train, he violated his own rules. He thought with his heart.
wo days after his birthday, on a Sunday Night, Dr. Matthew called his wife. She was startled by the sound of his voice. He was heavily
congested and coughing. "Margaret," he said, "I have a terrible flu."
Monday morning he had a fever. At the hospital infirmary, he told Sister Maria he had malaria. She agreed it must be malaria.
"We said malaria, but we thought Ebola," Sister Maria said. The fever grew worse as the day went by. He canceled meetings and went home
to bed. By Tuesday, antimalarial drugs had not brought down his fever. By Wednesday morning, he was vomiting, and he found it difficult to keep liquids down. Dr. Pierre Rollin from the C.D.C. ran blood tests. They were done at a lab on the hospital compound.
That night, Grace Obuu, 24, who became a nurse at St. Mary's after Dr. Matthew and his wife adopted her, went to his house. He was alone, and she put him on an IV drip to help keep him hydrated. His fever was high, and he was very weak, the nurse said, but he had stopped vomiting. She was startled by the sound of his voice. He was speaking loudly and distinctly, and he was not talking to her.
"Oh, God, I think I will die in my service," he prayed. "If I die, let me be the last." Then, in a powerful voice, he sang "Onward Christian Soldier."
Two years earlier in a Pentecostal church in Kampala, Dr. Matthew had delighted his born-again wife by raising his hand and announcing to the congregation that he, too, was born again. Always a churchgoing Protestant, he had since been going to church twice a week, until the "strange disease" called him away from Kampala.
The blood test came back positive for Ebola. "When I told him, he himself asked to go to the isolation ward," Dr. Rollin said.
"He said, 'Since I am the boss, I should show an example.' " A telephone call was finally placed on Thursday afternoon to Margaret, who had
heard nothing since Sunday night. Dr. Matthew had not wanted her called, saying he feared that she would take the call on her mobile phone while driving in traffic and would get in a wreck.
She was sitting on a sofa at home when the phone rang. She immediately packed her bag, hired a taxi and left for Gulu. But she
was late reaching an upcountry bridge across the Nile River. Soldiers block it at night as a security measure against the Lord's Resistance Army. Margaret had to sleep in the taxi.
On Friday morning at 9:30, dressed in protective gear, including goggles, she approached her husband's bedside. He was in Room 4 in the Ebola ward, next to the room where Simon Ajok died 11 days earlier. At the sight of him, Margaret began to cry, and she rushed toward his bed to hug him.
"Don't you come close to me!" Dr. Matthew warned. "You will get infected."
He called a doctor, who brought Margaret a stool. She sat about three feet away.
"You can't stay here when you are crying," he told his wife. "You will get infected. You don't have to cry. You have to be strong and only pray."
She stopped crying. He asked her how the children were doing in school. He was particularly worried, she said, that Peter was not paying proper attention to math.
After about 15 minutes, he seemed tired, and she left. That evening, he was stronger, as Margaret remembers, and his eyes were clear. He said that he probably got Ebola from Simon Ajok, and he struggled to explain why he took the risks that made him ill.
"Look, Margaret, it is a rough time, I know," he said. His wife recalled his words with reverent precision, as if she were reciting from Scripture. "You were not expecting this. God's will is not our will. I did not also expect to get, you know, infected. But being a person working in the foreground in this place, anything can happen. A mechanic can get his hands chopped off in a machine. Even a woman when she is cooking can get burned. So you just have to accept the situation."
Margaret became angry. "Now I can't even touch you," she told him. "I can't even nurse you. I can't do anything. I just have to sit aside like a traitor."
"You have to accept your fate," he replied. "I don't want you to get infected. If anything happens to me, at least you will be alive to look after my children."
On Saturday, his breathing was worse. He found it difficult to speak. Ignoring his warnings, Margaret moved close enough to touch her husband through the four surgical gloves she wore on each hand. During her 20-minute visits, she held his foot.
Dr. Matthew was getting weaker by the hour, exhausting himself as he fought for breath. On Sunday afternoon his doctors asked Margaret's permission to put him on a respirator. She gave permission, but before the machine was hooked up, she went to his bedside and asked him to pray with her.
"I said, 'Be strong, fight this sickness with the blood of Jesus,' " Margaret said. He complained that he was dry and, until the doctors shooed her away to hook up
the respirator, she slipped ice cubes into his mouth with her gloved fingers. The breathing machine seemed to be the answer. When Margaret left her
husband's bedside early Monday evening, his fever had come down, the oxygen level in his blood had risen and his pulse was near normal. One doctor told her it was a miracle. Late Monday night, however, his lungs hemorrhaged. This was the worst-case scenario his doctors had feared, and they could do nothing.
Dr. Matthew died at 1:20 a.m. on Dec. 5. By the time Margaret was notified and ran to the Ebola ward, he had been zipped up in a polyethylene body bag. She asked
that it be unzipped just a little so she could see his face for the last time. The corpse, she was told, was too infectious. The answer was no.
octors who treat Ebola are not convinced that they have a whole lot to offer any patient. They estimate that using IV drips to replace lost fluids
might make a difference for about 10 percent of those who get sick. For others, they guess, the seriousness of the illness depends on the genetic makeup of a patient, the amount of tainted blood or other body fluid that has come in contact with a patient and the route of infection. The prick of a bloody syringe, for example, is almost certainly worse than a cough in the face.
It also depends on the strain of the virus. In Congo in 1995, about 80 percent of those infected with Ebola died. But the strain of the virus that the C.D.C. isolated in northern Uganda was different from what they found in Congo and considerably less deadly.
It was identical to a strain that caused two Ebola outbreaks in nearby southern Sudan in the late 1970's. There, in a place where medical care was all but nonexistent, the death rate was around 50 percent -- roughly the same as it was last year in the best Ugandan hospitals. The numbers suggest that modern medicine, at least so far, is helpless to change the rate at which the various strains of Ebola kill human beings.
"Ebola is a tough disease," Dr. Bausch said. "I am not so sure that once someone is infected that the treatment we offer prevents more people from dying than would have died anyhow. The saddest example of that is Dr. Matthew. When he got sick, people pulled out all the stops. But it didn't matter."
Ebola is also finicky, depending on who gets infected. The same viral strain, acquired in the same way on the same evening, from the same infectious patient, can kill one person, while giving another a headache. Babu Washington Stanley, the night-shift nurse, also got sick with Ebola nine days after he and Dr. Matthew struggled to care for Simon Ajok. Stanley, though, came down with the mildest case of Ebola on record in Uganda. He had a headache for a few days, and
then it went away. Ebola made him hungry, he said, especially for liver. Now he is fine.
here is an amateur videotape of Dr. Matthew's burial. It is almost unbearable to watch.
According to a will he wrote in the Ebola ward in the days before his death, a grave was chosen inside the hospital compound beneath a towering banyan tree. It lay beside the grave of Lucille Teasdale, the surgeon who was the wife of Dr. Corti. Dr. Teasdale, who died of AIDS she contracted while operating on patients at St. Mary's,
had been Dr. Matthew's mentor, champion and great friend. Since his body was highly infectious, he was buried the day he died. An Ebola
burial team, dressed in protective gear that seemed suitable for a lunar landing, rolled up to the grave site at 4 p.m. in a white ambulance. They whisked a simple wooden coffin out of the ambulance and lowered it into the grave with ropes. All the while, one member of the burial team sprayed the coffin, the ropes and his colleagues with Jik bleach. More a disposal procedure than a burial, it was over in less than five minutes.
'I will not be able to come to you there because we are very busy, and secondly because it would be dangerous,' Dr. Matthew wrote to his wife. ' . . . You should not also come here! The situation is very bad!'
On the videotape, at the moment the ambulance comes into view, the soundtrack explodes with the screaming of nurses. Earsplitting and inconsolable, in voices that fused grief, exhaustion and rage, their shrieking was the hopeless music of the funeral. The nurses were part of a crowd of several hundred people who had been warned to stay well away from the grave until it was covered with dirt.
Margaret stood at a distance with her children. She had insisted that they witness the burial. Otherwise, she believed it would be impossible for them to accept their father's death. They arrived from Kampala just 30 minutes before the service.
Many government officials, including the minister of health, had also rushed north to Gulu. During the height of the Ebola epidemic last fall, Dr. Matthew had been quoted almost daily in the Ugandan press. He had become a national icon: the fearless field commander at the center of a biological war that threatened everyone in the country. Even though the Ebola outbreak had been all but defeated by the time he died, Dr. Matthew's death rattled the country's self-confidence, suggesting somehow that the center could not hold.
For a time, the doctor's death paralyzed Uganda's fight against what was left of the Ebola epidemic. St. Mary's Hospital stopped admitting new Ebola patients. Across Gulu District, a number of health-care workers quit. Suspected Ebola patients refused to be taken to hospitals. According to Dr. Onek, the health officer for Gulu District, local people were asking, "Why go to the hospital, if the big doctor
has died in the hospital?" Six weeks after the funeral, during a long and mournful conversation about the
consequences of Dr. Matthew's death, Sister Maria said St. Mary's had not yet recovered, and she doubted that it ever would. The hospital has not been able to find a new medical superintendent.
"You know, so many people relied on him," she said. "He had clear ideas about
what to do with the future of the hospital. We have lost a guide. He was so clever in a way of talking to you kindly. He could lead people. That is what we have lost."
Margaret, too, felt lost. President Museveni praised her husband's courage and promised her about $2,800 as a special death benefit. But that would not be nearly enough, Margaret said, to finish building a house in Kampala or to send five children to university, as her husband had planned. She said she did not know how she would be able to honor his wishes.
he doctor who made the mistake of thinking with his heart left far more behind than a vacuum.
Epidemiologists who traveled to Gulu credit Dr. Matthew with helping to contain Ebola before it could spread. His insistence on immediately calling senior health officials in Kampala jump-started the government's public-awareness campaign. He may have saved hundreds, perhaps thousands, of lives.
As important for containing future outbreaks, C.D.C. virologists said his support for their research means that Uganda's epidemic should produce more scientific data on Ebola than all the other outbreaks in Africa combined.
"If you need it, you have it," Dr. Matthew told foreign researchers when they descended on Uganda, according to Dr. Rollin.
Access to St. Mary's laboratories allowed researchers to preserve a vast number of blood samples from Ebola patients at every stage of infection. The samples could help them discover how Ebola triggers a cascade of immunological events that turn the body's defenses against itself, transforming white blood cells into subversive agents that trigger bleeding. The samples could also help them understand -- and perhaps one day invent a drug to inspire -- the remarkable immune response that allowed Babu Washington Stanley to shake off Ebola as if it were a mild hangover.
Father Odong, the vicar general of Gulu, said that he hoped his friend's story will offer his fellow Africans a new definition of what it means to be a big man in Africa. "It is not about getting rich and having power," he said. "We should tell everyone the story of Dr. Matthew."
Whether or not his story survives, its last chapter did turn out as Dr. Matthew had hoped.
His hospital and his nation defeated Ebola, at least this time around. With no new cases in the previous 21 days, W.H.O. declared on Feb. 6 that the
epidemic was effectively over. The isolation ward at St. Mary's has been closed and scrubbed down and will reopen this month as a children's ward. And Dr. Matthew's solitary prayer in the week before he died was answered: among the health-care
workers who fought Ebola at St. Mary's, he was the last to die.
