PMC Boss Pleads For Help But None Come Forward To Take His Bleeding Son To Hospital

One skeptic—perhaps the most influential and thus the most disastrous—was WHO, the health arm of the U.N. Underfunded and overly bureaucratic, WHO is, in the eyes of its many critics, woefully inadequate in dealing with rapidly emerging threats like Ebola. Worse perhaps, the agency’s local representatives are notoriously jealous of their turf and prerogatives. At this same critical moment, WHO offices in West Africa turned away a team of experts from the CDC working in Guinea, insisting that their help was not needed, says CDC director Dr. Thomas Frieden. The CDC, a large and very well-regarded public-health agency, is unsurpassed in its capacity for action, maintaining some 2,000 field workers in 60 countries around the world. Those workers in turn can often summon resources from the U.S. to smother epidemics in their infancy abroad.

Teamwork at this early moment might have saved thousands of lives and ultimately billions of dollars in direct and indirect costs stemming from the Ebola epidemic. Instead, WHO closed the door, says Frieden.

The CDC would be back in the summer, when Ebola was running wild, to train local volunteers in the crucial techniques of tracing and evaluating the contacts of Ebola patients. By then, however, the challenge would be incalculably greater.

Frieden says he intervened personally with WHO’s top leadership. “I had to get directly involved,” he explains, telling his counterparts, “Let our team in. This is ridiculous.” (A spokesperson from WHO told Time that “no one in Geneva knows of anything regarding CDC” being asked to leave Guinea in March.) The CDC specialists believed they had a chance to control the epidemic if they worked with local health authorities and other groups in the region. But Frieden’s protests changed nothing. “They wanted to do it themselves—there was resentment.” Summing it up, he says, “WHO didn’t want us there, so we left.”

Director of the Centers for Disease Control and Prevention Dr. Tom Frieden

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videoCaption=Dr. Tom Frieden, 54, director of the Centers for Disease Control and Prevention: “We can’t make it zero here until we stop the epidemic in West Africa. It’s going to be a long, hard fight.”|

credits=Bryan Schutmaat for TIME|



In Monrovia, Jerry Brown found himself wondering if he had converted the hospital chapel in vain. April turned to May, and still Ebola had not reached the capital. There was one close call: an infected traveler from Lofa County commuted through the city on her way to the town of Harbel, where she died. But Dr. Mosoka Fallah, a Harvard-educated Liberian epidemiologist, rushed to the home of the taxi driver who had picked up the traveler and persuaded him to accept a 21-day quarantine. The three weeks passed—the full incubation period for Ebola—with no new signs of disease. Monrovia remained untouched.

Brown contacted the Ministry of Health in early June to ask if he should dismantle ELWA’s isolation unit. The official who took his call suggested waiting a few more days, just in case.

On June 12, after a late evening in surgery, Brown emerged from the operating room to find a string of missed calls on his cell phone. Ringing back, he reached the same official, who asked if the chapel facility was still ready. Two patients, visitors from Sierra Leone who were staying in New Kru Town, an area populated by immigrants, had turned up at the government-run Redemption Hospital in Monrovia with suspicious symptoms. Medical staff examined them without protective gear. “They most likely have Ebola,” the ministry official said, according to Brown. “And the only place I thought about that we could keep them until we have an investigation done is at your center.”

Brown dreaded the impact of welcoming Ebola into his hospital, but he felt he had no moral choice but to absorb it. He knew his fellow doctors would stand with him, but the nurses were another matter. They initially refused to mix disinfectant and don protective gear for the work unit. “If you want my resignation, I will give it to you,” one told Brown. “I would rather leave than attend to an Ebola patient.” Another nurse said she felt too sick to stay at work. “I developed a headache a couple of minutes ago,” she said.

With all their work thus far at stake, the doctors tried personal appeals to their favorite nurses. Brantly circled around to the nurse with the headache, and after a little cajoling, she agreed to work in the isolation unit—but not alone. The doctors continued to plead with staff until they found a nurse’s aide and an operating-room technician willing to suit up.

Covered head to toe in Tyvek gear, goggles and masks, this cobbled-together team was ready when the ambulance from Redemption pulled into the ELWA compound two hours after the official’s call. Brown was shocked to see the ambulance crew dressed in ordinary scrubs.

One of the patients lay dead inside the vehicle. Brantly rushed the other patient into the chapel; that patient died a couple of days later, according to Brown. A nurse from the ambulance was likewise doomed, along with a doctor who did the initial screening at Redemption. Ebola had reached the city.

But it was even worse than that, as the Liberian epidemiologist Fallah quickly came to understand. He knew that an epidemic is not a simple matter of the sick people you can see. Even more important is the web of individuals who touch the sick or are touched by them. To control a contagion, it’s not enough to treat the visible patients; you must find and contain every strand and tendril of the web.

Fallah retraced the steps of the patient who died in ELWA’s chapel to a house in the Monrovia slum of New Kru Town, home to many Sierra Leonean immigrants, where he encountered “a strong feeling of denial” about the virus. One woman he approached gave a typical reply: “If anyone says they have Ebola in this house, I will give you a slap.” To acknowledge the disease was to invite social stigma and financial ruin.

“This was a six-bedroom house, but in New Kru Town, typically every room is a household,” Fallah says. “And we were counting between five to 10 or so in a room. So we’re looking at between 30 to 60 persons.”

Through dogged investigation, Fallah soon learned the identity of the person who drove the patients to Redemption Hospital and confirmed that the driver’s sister was dead of the disease. He learned that the driver had disappeared. And he determined that those contacts had other contacts—the strands of a web that Fallah followed until he discovered the identity of a contact who had been vomiting in the street. Yet other contacts (his heart fell when he realized this) had visited “a communal bathroom that all the houses use.”

This is a classic example of contact tracing, and it’s critical to fighting infectious disease. Watson-Stryker and others were doing much the same thing in Guinea and Sierra Leone. The network of contacts that Fallah unearthed revealed that Ebola had been simmering in Monrovia for some time. “Things were going on that we didn’t know about,” he says. “People visiting clinics. Some of them went to the church.” But none of it had been reported. Fear, shame and ignorance combined to keep Ebola shrouded. This was a terrible revelation, says Fallah. “It blew our minds.”

A Chain Reaction

Ebola’s lurking presence in the capital gave it a head start once it revealed itself in mid-June, and Monrovia’s fragile patchwork of health care providers was quickly overwhelmed.

The meltdown began in early July at Redemption, a single-story structure painted swimming-pool green and blazoned with murals that explain the importance of personal hygiene and antimalarial mosquito nets. Redemption Hospital’s lack of preparation ignited a chain reaction of infection and death: a nurse, a doctor, a medical aide. Frightened staff members vanished from their posts, forcing the hospital to close temporarily at a time of desperate need.

Other health workers at other clinics quickly followed. (Brown and his colleagues somehow managed to keep ELWA functioning.) Institutions that might have taken up some slack as clearinghouses for information to fight the epidemic—schools and government offices—also began shutting down, and many senior bureaucrats fled the country. President Ellen Johnson Sirleaf appeared stunned, frozen in place, unable to declare an emergency until seven weeks after the Redemption disaster. It was alarming how rapidly the yoked contagions of virus and fear unhinged Monrovia.

Within days of the June 12 call, ELWA’s six-bed chapel was overwhelmed. The Ministry of Health scrambled to create a rudimentary 20-bed Ebola treatment unit (ETU) at the state-run John F. Kennedy Hospital, and the new facility was beyond capacity almost as soon as it opened. At least two dozen people died in Monrovia in the early days after Ebola’s arrival.

More beds were needed. Brown decided to convert the brand-new kitchen and laundry building donated by Samaritan’s Purse. An emergency check from the organization, which was founded by the Rev. Franklin Graham—son of the evangelist Billy Graham—provided for building materials and more protective gear. Samaritan’s Purse also sent its director of disaster response, Dr. Lance Plyler, to join the battle. Hastily completed in July, ELWA 2, as the facility became known, had room for an additional 20 beds.

Still, it wasn’t enough. “Within a week it was filled,” Brown says. “People were now in the corridors, under the eaves of the building. Patients were just pouring in on a daily basis.”

Brown and Brantly had agreed early on that Brantly would handle the Ebola cases while Brown kept the rest of the hospital going. As July crept along one wretched day after another, matters became so chaotic at ELWA that Brown didn’t immediately notice when Brantly went missing from the treatment unit. When, late in the month, he noticed and asked for an explanation, Dr. Fankhauser broke the news that their colleague was feverish and had put himself in quarantine at home.

Evidently, Brantly had been exposed to the virus while performing triage in ELWA’s emergency room. During an overnight shift, a woman brought her suffering mother into the ER for help. Brantly wore a gown, gloves and face mask but not the full protective suit, because the suit “scares people, and they won’t necessarily tell you the truth,” he explains.

During the examination, the woman’s mother needed help from her daughter in making an urgent trip to the bathroom. Brantly suspected Ebola. He took the woman aside to explain why her mother needed to go to the ETU. “I had to counsel her extensively to reassure her that we were trying to do what was best for her mother—we were not abandoning her,” the doctor says. “I took off my mask, gloves and apron when I talked to her, and I probably held her hands or put my arm around her shoulder, as I often do.” Brantly doesn’t think he was infected by the mother. But the daughter had taken her to the toilet, and there’s a chance she hadn’t washed her hands afterward.

There was more bad news for Brown. On July 26, ELWA’s personnel coordinator, Nancy Writebol—a medical aide from North Carolina who worked with Serving in Mission—tested positive for Ebola. Within a few days, two other employees had been infected. Once again, Brown had to talk his way through a possible staff walkout.

It was late July now, and Ebola had pushed Jerry Brown and his hospital to its breaking point. On a personal level, he was now forced to do something he had promised his wife he would not do: suit up in Tyvek and go to work in the ETU. Every willing hand was needed, and the fearful staff must see that the boss had enough courage to do as much as he asked of them, he says.

Brown also made a painful decision to close the main hospital for a few days and limit some services after that. Though malaria season was coming on and expectant mothers counted on ELWA for childbirth, Brown felt he had no choice. Not after one of his own nurses, down with Ebola, was turned away for want of a bed.

Anatomy of a Virus

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