Tom Frieden remembers the young woman with the beautiful hair, dyed a rusty gold and braided meticulously, elaborately, perhaps by someone who loved her very much. She was lying facedown, half off the mattress. She had been dead for hours, and flies had found the bare flesh of her legs.
Two other bodies lay nearby. Bedridden patients who had not yet succumbed said of the dead, "Please, get them out of here."
Frieden, the director of the
U.S. Centers for
Disease Control and Prevention (CDC), knew it was no simple matter to properly carry away a body loaded with Ebola virus. It takes four people wearing protective suits, one at each corner of the body bag. On that grim day near the end of August, in a makeshift
Ebola ward in Monrovia, Liberia, burial teams already had lugged 60 victims to a truck for the trip to the crematorium.
ABOVE: A sick child, Cynthia, waits outside Redemption Hospital in Monrovia, Liberia, for health workers to remove dead bodies before she can enter.
Frieden had seen plenty of death over the years, but this was far worse than he expected, a plague on a medieval scale. "A scene out of Dante," he called it.
Shaken, he flew back to the
United States on Aug. 31 and immediately briefed President Obama by phone. The window to act was closing, he told the president in the 15-minute call.
That conversation, nearly six months after the
World Health Organization (WHO) learned of an Ebola outbreak in West Africa, was part of a mounting realization among world leaders that the battle against the virus was being lost. As of early September, with more than 1,800 confirmed Ebola deaths in Guinea, Liberia and Sierra Leone, there was still no coordinated global response. Alarmed U.S. officials realized they would need to call in the military.
Obama eventually ordered 3,000 military personnel to West Africa; about 200 had arrived by the beginning of this month. They will be joined by health workers from countries such as Britain, China and Cuba. Canada and Japan are sending protective gear and mobile laboratories. Nonprofit organizations such as the Gates Foundation also are contributing. But it's not at all clear that this belated muscular response will be enough to quell the epidemic before it takes tens of thousands of lives.
This is an open-ended crisis involving a microscopic threat on the move. This week came the unsettling news that the Ebola epidemic has now reached across the Atlantic Ocean to a hospital in Texas, where a Liberian man has tested positive for the virus.
So how did the situation get so horribly out of control?
The virus easily outran the plodding response. The WHO, an arm of the United Nations, is responsible for coordinating international action in a crisis like this, but it has suffered budget cuts, has lost many of its brightest minds and was slow to sound a global alarm on Ebola. Not until Aug. 8, 4 1 ⁄ 2 months into the epidemic, did the organization declare a global emergency. Its Africa office, which oversees the region, initially did not welcome a robust role by the CDC in the response to the outbreak.
Previous Ebola outbreaks had been quickly throttled, but that experience proved misleading and officials did not grasp the potential scale of the disaster. Their imaginations were unequal to the virulence of the pathogen.
"In retrospect, we could have responded faster. Some of the criticism is appropriate," acknowledged Richard Brennan, director of the WHO's Department of Emergency Risk Management and Humanitarian Response. But he added, "While some of the criticism we accept, I think we also have to get things in perspective that this outbreak has a dynamic that's unlike everything we've ever seen before and, I think, has caught everyone unawares."
The epidemic has exposed a disconnect between the aspirations of global health officials and the reality of infectious disease control. Officials hold faraway strategy sessions about fighting emerging diseases and bioterrorism even as front-line doctors and nurses don't have enough latex gloves, protective gowns, rehydrating fluid or workers to carry bodies to the morgue.
"We cannot wait for those high-level meetings to convene and discuss over cocktails and petits fours what they're going to do," exclaimed Joanne Liu, international head of Doctors Without Borders, when she heard about another U.N. initiative. Her group was among the first to respond to the viral conflagration, and it kept its staff in West Africa throughout the crisis.
West Africa was ill-equipped for an Ebola disaster because civil war and chronic poverty had undermined local health systems and there were few doctors and nurses. Health workers in the region had never experienced an Ebola outbreak and didn't know what they were seeing in those first critical months. In the spring the outbreak seemed to fade, making officials overconfident. And then the virus made the leap from rural villages to crowded cities.
Local customs in handling the dead led to further infections. Some West Africans believe that the day you die is one of the most important days of your life. The final farewell can be a hands-on, affectionate ritual in which the body is washed and dressed, and in some villages carried through the community, where friends and relatives will share a favorite beverage by putting the cup to the lips of the deceased before taking a drink.
And finally, the virus itself played a critical role in accelerating the crisis. Ebola, although not nearly as contagious as some viruses, is unusually lethal and commensurately terrifying. Many foreign health workers and volunteers fled the region, and few people rushed in to take their place.
This is both a biological plague and a psychological one, and fear can spread even faster than the virus.
'This is relatively small still'
A virus is not really alive, in the formal sense of the word, as it cannot do anything outside of a host. Ebola is a filovirus, and looks like a piece of spaghetti. The protein envelope surrounds a strand of RNA, the simpler cousin of DNA. You could say it is pure information with instructions for replication.
Ebola is one of a number of viruses that cause "viral hemorrhagic fever." What makes it so deadly is that it can take over the machinery of many kinds of cells, replicating quickly. It shuts down or misdirects parts of the immune system and sends the rest into hyperdrive, causing the victim to suffer fever, headaches, vomiting, diarrhea and dehydration. Death can come within days from multiple organ failure.
Ebola isn't nearly as contagious as, say,
measles or influenza. It is transmitted only through bodily fluids after the fever and other symptoms have occurred. But the incubation period, after infection and before the person becomes symptomatic, typically lasts about a week, or as long as three weeks. People who are infected can travel a great distance before they begin to shed the virus. Initial symptoms are similar to those caused by malaria and influenza, confounding a proper diagnosis.
The first Ebola cases surfaced in late 2013 in Guinea, in the rain forest in the district of Guéckédou, close to borders with Liberia and Sierra Leone. No one knows exactly when the virus jumped into the human population, or from which animal species - a fruit bat is one possibility - but the first victim is believed to have been a 2-year-old girl or someone close to her.
Doctors at first assumed they were looking at Lassa fever, a viral hemorrhagic fever similar to Ebola, as dozens of people began falling sick and more than half of them were dying. But then on
March 23, the WHO posted a notice on its Web site:
"The Ministry of Health (MoH) of Guinea has notified WHO of a rapidly evolving outbreak of Ebola virus disease (EVD) in forested areas of south-eastern Guinea. As of 22 March 2014, a total of 49 cases including
29 deaths (case fatality ratio: 59%) had been reported."
The virus spread from Guinea to Liberia, where two people died in late March. On April 1, Sierra Leone reported that two of its citizens had died in Guinea, probably from Ebola, and that their bodies had been returned to their native country
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