Western African Ebola epidemic

• 1. Introduction

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  In December 2013, a boy of perhaps one or two years old died in Méliandou, a village in Guinea. He is generally believed to have been the first case of the Western African Ebola epidemic, and he was later identified as Emile Ouamouno. His mother, his sister and his grandmother later fell ill with similar symptoms, and they died as well. People infected by these first victims carried the disease to other villages. What followed became the most widespread Ebola outbreak in history, centered on Guinea, Liberia and Sierra Leone.

  This documentary asks why a disease first discovered in 1976 spread so far this time. It asks what happened to the people who lived through it, from burial teams to nurses to ordinary families. And it asks why an epidemic that seemed to be ending kept returning in small, unexpected flare-ups.

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• 2. Months of Silence

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  Méliandou's early victims were diagnosed with other conditions common in the area. The disease then had several months to travel before anyone recognised it as Ebola. Extreme poverty, failing health systems and distrust left behind by years of armed conflict all helped the virus along. So did its unprecedented arrival in densely populated cities.

  On the 25th of March 2014, the World Health Organization said Guinea's Ministry of Health had reported Ebola in four southeastern districts. As of the 24th of March, the count stood at 86 suspected cases, including 59 deaths. Suspected cases in neighbouring Liberia and Sierra Leone were also under investigation. By late May the virus had reached Conakry, Guinea's capital, a city of about two million people. On the 28th of May, reported cases totalled 281, with 186 deaths.

  Dr Peter Piot, the scientist who co-discovered the virus, saw something new in all this. Earlier outbreaks had mostly followed a more linear pattern in remote regions. This time, he said, the virus was "hopping" all over the region. It had also entered large cities, where an infected person can have many more contacts. That made transmission harder to track and break.

  By the 17th of July, Sierra Leone alone had 442 suspected cases, surpassing both Guinea and Liberia.

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• 3. Burial and Belief

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  On the 26th of May 2014, a tribal healer died in Sierra Leone after treating Ebola patients who had crossed over from Guinea. Tradition called for her body to be washed for burial, and the infections that followed appear to have started there. Researchers traced the first wave to 13 women who attended her funeral. Their genetic work showed at least two distinct lineages entering from Guinea at about the same time. They called it "the first time that the real evolution of the Ebola virus could be observed in humans." It remains unclear whether the healer carried both lineages or a mourner was infected separately.

  An August 2014 study found that nearly two-thirds of Ebola cases in Guinea were believed to trace back to burial practices, including washing the body. In November, the WHO released a protocol for safe and dignified burial. On the 27th of January 2015, Guinea's Grand Imam, the country's highest cleric, spoke plainly. "There is nothing in the Koran that says you must wash, kiss or hold your dead loved ones," he said. He urged safer rituals that would not compromise tradition. In Liberia, Roselyn Nugba-Ballah led the Safe & Dignified Burial Practices Team, and she received the Florence Nightingale Medal in 2017.

  Fear ran just as hot as grief. In Liberia, a mob attacked an Ebola isolation centre, stealing equipment and "freeing" patients while shouting "There's no Ebola." Red Cross staff in southeast Guinea suspended operations after men armed with knives threatened them. In the Guinean town of Womey in September, suspicious inhabitants wielding machetes murdered at least eight aid workers. Language barriers and the sight of medical teams in protective suits sometimes deepened the dread. On the 14th of February 2015, violence destroyed a treatment centre near the middle of Guinea, and Guinean Red Cross teams reported an average of 10 attacks a month over the previous year.

  The director of the charity Plan International in Guinea described a harder problem in Conakry. "People do not think to wash their hands when they do not have enough water to drink," he said. Schools across the three worst-hit countries closed for months. When classes resumed in January 2015, UNICEF and its partners had installed hand-washing stations and handed out millions of bars of soap and chlorine, even though fewer than half of the schools had running water. By August 2015, UNICEF reported no student or teacher infected at a school since those protocols began.

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• 4. Quarantine and Surge

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  On the 8th of August 2014, a cordon sanitaire went up in the triangle where Guinea, Liberia and Sierra Leone meet along porous borders. This practice forcibly isolates affected regions, and about 70 percent of the known cases lay inside that triangle. It was later replaced by roadside checkpoints for hand-washing and temperature checks, staffed by local volunteers or the military.

  On the 2nd of September 2014, WHO Director-General Margaret Chan advised against travel restrictions. She said they were not justified and would keep medical experts out of the affected areas. The medical charity MSF went further and called border closures "another layer of collective irresponsibility." Even so, on the 27th of July President Ellen Johnson Sirleaf had announced that Liberia would close its borders, except a few crossings such as Roberts International Airport, where screening centres would open. Schools and universities shut, and the worst-hit areas were quarantined.

  Sierra Leone closed its borders for trade with Guinea and Liberia on the 11th of June and shut some schools. On the 30th of July, the government began sending troops to enforce quarantines. By the 4th of November, media reports said thousands had broken quarantine in the town of Kenema while searching for food. The Disaster Emergency Committee warned that shortages caused by aggressive quarantines were making the crisis worse.

  An MSF coordinator called the situation in Sierra Leone "catastrophic." In the coordinator's words, "there are several villages and communities that have been basically wiped out... Whole communities have disappeared but many of them are not in the statistics." On the 9th of December, news reports described "a grim scene" in the remote eastern Kono District, with piles of bodies and exhausted burial teams. By the second week of December, Sierra Leone had reported nearly 400 cases, more than three times Guinea's and Liberia's combined. On the 17th of December, President Koroma launched Operation Western Area Surge, and workers went door to door in the capital. The operation produced 403 new case reports between the 14th and the 17th of December.

  The CDC voiced a darker fear: "the risk we face now is that Ebola will simmer along, become native and be a problem for Africa and the world, for years to come."

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• 5. Beyond the Borders

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  On the 20th of July 2014, a Liberian-American flew from Liberia to Lagos, Nigeria's most populated city. The WHO later counted 20 confirmed cases and 8 deaths, including him. Four of the dead were health workers who had cared for him. Credit went largely to the early quarantine efforts of Dr Ameyo Stella Adadevoh. On the 20th of October 2014, the WHO's representative in Nigeria declared the country Ebola-free and called it a "spectacular success story." Nigeria was the first African country to earn that declaration.

  Senegal had closed its southern border with Guinea in March 2014. Even so, on the 29th of August its health minister announced a first case, a native of Guinea who had reached Dakar on the 20th of August. An alert from Guinea on the 28th said a close contact had escaped surveillance. That alert prompted testing at the Dakar laboratory and urgent contact tracing. The patient recovered, and the WHO declared the Senegal outbreak over on the 17th of October 2014.

  On the 23rd of October 2014, a two-year-old girl who had arrived from Guinea died in Kayes, Mali, the day after her case was confirmed. Her father had worked for the Red Cross in Guinea and in a private clinic, where he likely caught the virus. A second chain began with an imam who fell ill in Guinea on the 17th of October and was moved to the Pasteur Clinic in Bamako. He was treated for kidney failure but not tested for Ebola, and he died on the 27th of October. A nurse and a doctor who treated him later died too. Mali was declared Ebola-free on the 18th of January 2015.

  On the 5th of August 2014, Brother Miguel Pajares, a volunteer in Liberia, was confirmed infected and flown to Spain, where he died on the 12th of August. A second Spanish citizen, Brother Manuel García Viejo, was evacuated from Sierra Leone and died, with his death announced on the 25th of September. Teresa Romero, a nursing assistant who had cared for these patients, tested positive on the 6th of October. Hers was the first confirmed transmission of Ebola outside Africa. She recovered, and the WHO declared Spain Ebola-free on the 2nd of December.

  On the 30th of September 2014, the CDC announced its first case, Thomas Eric Duncan. He had become infected in Liberia and travelled to Dallas, Texas, on the 20th of September. He fell ill on the 26th, sought care and was sent home with antibiotics. An ambulance brought him back on the 28th, and he died on the 8th of October. Two nurses who treated him tested positive, and a fourth US case followed on the 23rd of October, when physician Craig Spencer, who had treated patients in Western Africa, tested positive. He was released on the 11th of November.

  Other cases were rarer. British aid worker Pauline Cafferkey was diagnosed in Glasgow on the 29th of December 2014. Her illness later returned, and doctors diagnosed meningitis caused by the virus persisting in her brain. An Italian nurse who had worked in Sierra Leone was diagnosed in Sardinia on the 12th of May 2015.

  One outbreak had nothing to do with any of this. In August 2014-13 people died of Ebola-like symptoms in the Boende District of the Democratic Republic of the Congo. Genetic sequencing showed a different, native strain, and the WHO declared it over on the 21st of November 2014, after 66 cases and 49 deaths.

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• 6. Armor and Exhaustion

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  A single set of protective clothing for the medical charity MSF cost about $75. It included a suit, goggles, a mask, socks and boots, and an apron. Only the boots and apron could be disinfected and reused. Staff said the gear was so heavy that they could stay in it for only about 40 minutes at a time. Taking it off took 20 to 25 minutes, with two trained supervisors watching each step. One physician in Sierra Leone explained why: "a slip-up can easily occur and of course can be fatal."

  Full training in putting on and removing the gear can take 10 to 14 days. By October, protective outfits were running short, and manufacturers began raising production. On the 17th of December 2014, a team at Johns Hopkins University built a prototype breakaway hazmat suit with a small battery-powered cooling pack on the wearer's belt. It earned a grant from USAID for further development.

  The people inside those suits paid heavily. In August 2014, the WHO reported that health workers made up nearly 10 percent of the cases and deaths. By the 1st of July 2015, 874 health workers had been infected and 509 of them had died. Liberia entered the crisis with only 50 physicians, roughly one for every 70,000 citizens. The WHO offered several explanations, including too few staff, shortages of equipment, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe."

  A CDC report in October 2015 found that Guinean healthcare workers were infected at 42.2 times the rate of other people. Doctors accounted for 27% of the infections among health workers there.

  In December 2014, the editors of Time magazine named the Ebola health workers their Person of the Year. Editor Nancy Gibbs credited them with "buying the world time to boost its defences."

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• 7. Care Under Pressure

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  On the 12th of September 2014, Margaret Chan told the world: "Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." The WHO estimated that the affected countries were short by the equivalent of 2,122 beds. A report on the 19th of September said Sierra Leone was meeting only 35% of its need for patient beds and Liberia just 20%. Liberia's ambassador in Washington feared his country might be "close to collapse," and by the 24th of October all 15 of its counties had reported cases. By December 2014 there were enough beds for all reported cases, though they were unevenly spread.

  On the 3rd of September 2014, WHO official Keiji Fukuda admitted, "We don't have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases." Tracing means finding everyone close to a patient and following them for 21 days. By the 23rd of November, workers had listed and traced 25,926 contacts in Guinea, 35,183 in Liberia and 104,454 in Sierra Leone. Later, every district could reach a laboratory that confirmed cases within 24 hours, and more than 80% of registered contacts were being traced.

  Paul Farmer of Partners in Health began treating Ebola patients in January 2015, and he pressed for intravenous fluids for everyone. Severe vomiting and diarrhoea drain the body, and without replacement fluids a patient can fall into hypovolaemic shock. Yet placing an IV needle through three pairs of gloves and fogged goggles is hard. Delirious patients can pull the line out, and electrolytes need lab monitoring that many areas lacked. MSF took a cautious view, arguing that poorly managed IV treatment could even kill. Farmer asked, "What if the fatality rate isn't the virulence of disease but the mediocrity of the medical delivery?" Looking back in 2020, he noted that almost no US and European patients died, because they received optimal care.

  Where hospital beds ran out, families sometimes had to nurse patients at home. UNICEF, USAID and Samaritan's Purse supplied caregiver kits with protective clothing, hydration items, medicines and disinfectant.

  The Wellcome Trust warned in October 2014 that "the additional death toll from malaria and other diseases is likely to exceed that of the outbreak itself." Many hospitals had closed for lack of staff or out of fear. Sierra Leone later documented the damage to mothers. Fear of hospitals cut facility-based births by 11%, and care before or after birth fell by about a fifth. Between May 2014 and April 2015, maternal deaths around childbirth rose by almost a third, and newborn deaths by a quarter.

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• 8. Survivors and Flare-ups

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  On the 9th of June 2016, the epidemic was declared over, 42 days after the last case tested negative in Monrovia on the 28th of April 2016. Cases had peaked in October 2014. In total, 28,616 people were infected and 11,310 died, a case-fatality rate of 40%. The WHO believes even the larger official counts understate the real size. The emergency status that had been declared on the 8th of August 2014 ended on the 29th of March 2016.

  The endings kept unravelling. Liberia was declared Ebola-free on the 9th of May 2015, but on the 29th of June a 17-year-old boy who had been treated for malaria tested positive. He had not travelled or attended a funeral. Three cases shared a meal of dog meat, which led researchers to suspect the animal, but testing of its remains was negative. On the 14th of September 2015, a 16-year-old girl died in Sierra Leone's Bombali District, and officials suspected she caught the virus from the semen of a survivor discharged in March. In November 2015, a 15-year-old boy in Liberia was diagnosed with no recent exposure, and the WHO suspected the virus had persisted in someone who had suffered the disease months before.

  In March 2016, Guinea reported fresh positives in Korokpara, and about 1,000 contacts were identified. Findings published in September 2016 suggested the resurgence began with a survivor who, after eight months of abstinence, had sexual relations with several partners. The WHO advised survivors in April 2015 to use condoms consistently beyond three months. A study released in September 2016 suggested the virus might survive more than 530 days.

  About 17,000 people survived, and many report lingering problems the WHO calls post-Ebola syndrome. Musculoskeletal pain affects up to 75% of survivors, and hearing loss has been reported in 25%. Some survivors develop uveitis or optic nerve disease, and a Sierra Leone physician in February 2015 had seen survivors go blind. A senior WHO consultant said that there were hardly any ophthalmologists in Western Africa. In December 2015, the UN announced that 22,000 children had lost one or both parents.

  In July 2015, researchers announced that a vaccine trial in Guinea appeared to protect people from the virus. The vaccine, rVSV-ZEBOV, was tested by ring vaccination, which vaccinates everyone around a suspected case. In December 2016, the full results showed it protected exposed people and also indirectly protected the unvaccinated through herd immunity. About 300,000 doses were stockpiled, and regulators including the US FDA approved it in 2019. In April 2018, it was used for the first time to stop an outbreak, in the Équateur province of the Democratic Republic of the Congo.

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