How Ebola Roared Back

Kevin Sack, Sheri Fink, Pam Belluck and Adam Nossiter; Photographs by Daniel Berehulak, How Ebola Roared Back. The New York Times, 29 December 2014. “For a fleeting moment last spring [2014], the epidemic sweeping West Africa might have been stopped. But the opportunity to control the virus, which has now caused more than 7,800 deaths, was lost.”

Dr. [Pierre] Rollin [the top Ebola expert at the Centers for Disease Control and Prevention] and other well-intentioned veterans of past Ebola campaigns…tragically underestimated this outbreak [spring 2014], overlooking clues that now seem apparent. Viewing the West Africa epidemic through the prism of nearly two dozen previous outbreaks across the continent, they failed to appreciate that the 2014 version would be unique in catastrophic ways.

After more than 20,000 cases and 7,800 deaths, it can be hard to recall that there was a moment in the spring when the longest and deadliest Ebola outbreak in history might have been stopped. But without a robust and coordinated response, an invisible epidemic was allowed to thrive alongside the one assumed to be contained.

Although conditions were ideal for the virus to go underground, some of the world’s most experienced Ebola fighters convinced themselves that the sharp decline in newly reported cases in April and May was real.

Tracing those exposed to Ebola and checking them for symptoms, the key to containing any outbreak, had been lacking in many areas. Health workers had been chased out of fearful neighborhoods. Ebola treatment centers had gained such reputations as deathtraps that even desperately ill patients devoted their waning strength to avoiding them.

With the affected countries often lacking the most basic medical infrastructure, the health care challenges proved staggering. But the most tragically missed opportunities stemmed from the poor flow of information about who was infected and whom they might have exposed.

A two-month investigation by The New York Times into this largely unexamined period discovered that the W.H.O. and the Guinean health ministry documented in March that a handful of people had recently died or been sick with Ebola-like symptoms across the border in Sierra Leone. But information about two of those possible infections never reached senior health officials and the team investigating suspected cases in Sierra Leone.

As a result, it was not until late May, after more than two months of unchecked contagion, that Sierra Leone recorded its first confirmed cases. The chain of illnesses and deaths links those cases directly to the two cases that were never followed up in March. Sierra Leone has since tallied about 9,400 reported Ebola infections, more than any other country. The same missed cases are linked to Liberia’s vast second-wave outbreak, identified in late May, with almost 8,000 reported infections to date.

The leaders of the initial response agree that they did not deploy nearly enough people to the region, and that they withdrew too soon. There was managerial confusion in the W.H.O., which was already stretched by budget cuts and competing demands. Some in the W.H.O. along with Guinean officials played down the threat, leading to overconfidence and inattention. Other international and nongovernment groups devised public-education campaigns that in some instances did more harm than good.

Dr. Peter Piot, who helped discover Ebola in 1976, and Jeremy Farrar, a British infectious disease specialist, called the West Africa outbreak “an avoidable crisis” in an editorial published online in September in The New England Journal of Medicine. In the same issue, W.H.O. officials said of the March to July period that “modest further intervention efforts at that point could have achieved control.”

Like all who followed them, the early responders demonstrated remarkable courage and dedication. But those qualities did not guarantee an understanding of how geography and culture would make this outbreak so distinctive.

Most previous outbreaks had started in remote villages in Central and East Africa, where the virus could be surrounded and isolated. All told, they had killed 1,590 people over four decades, only a fifth of the toll of the epidemic still unfolding across West Africa.

In some of the worst luck in epidemiological history, this outbreak occurred at the bustling intersection of three of the world’s poorest and least developed countries. Doctors in the region were rarer than paved roads — Liberia, for instance, had fewer than 250 physicians for four million people — and clinics and hospitals, where they existed, often lacked essentials like running water, hand soap and gloves….

Distrust of government ran so high after decades of civil war and corruption that many West Africans had to be convinced Ebola was real and not a plot to attract foreign aid. They reacted with indignation to outsiders who demanded they stop providing hands-on care to the sick, considered a sacred obligation by many West Africans, whether Muslim, Christian or traditionalist.

Governments attempted to broadcast the message that Ebola was spread through contact with vomit, feces and blood, and that bodies remained highly contagious after death. But communities often continued to wash the bodies of the dead, a step considered essential to a dignified burial and a contented afterlife. The arrival of moon-suited health workers in convoys of white trucks, armed with chlorine sprayers and thermometers, bred resistance and secrecy….

[A] lack of resources was not the W.H.O.’s only problem. Its clunky governance structure and overlapping power bases invited political meddling and sowed confusion on the ground…. The paucity of health care in West Africa meant that the W.H.O.’s central coordinating role would be critical. But its capacity had shrunk. In recent years, its epidemic response department, including a network of anthropologists to help overcome cultural differences, had dissolved, with duties parceled out to other branches….

Denial and stigma had always posed obstacles to containing Ebola outbreaks. But the early responders in West Africa arrived with little understanding of the long-exploited region’s deeply rooted suspicions of outsiders and government.

From the 16th century to the 19th, its inhabitants were captured by slave raiders and shipped to Europe and the Americas. During the era when Guinea was a French colony, the people of the Forest Region were forced to build roads and tap rubber, up to the 1940s. After independence, Guinea’s authoritarian ruler sought to suppress their indigenous culture and ancestral beliefs, while conscripting much of their harvests of rice, coffee and palm oil.

It did not take long for resistance in the villages to grow aggressive. Relief workers confronted accusations that they had brought Ebola to Guinea themselves. They heard assertions that the disease was a curse, or a scheme to sell body parts.

On April 4 in Macenta [Guinea], a seething crowd chased a surveillance team from a neighborhood and sacked the Doctors Without Borders treatment center, forcing it to close for a week….

Ill-conceived early efforts might have helped drive the outbreak into the shadows. Many fliers, posters and radio advertisements inadvertently reinforced a hopeless message that Ebola had no cure, deepening people’s fears that they would be cut off from dying relatives if they took them to health centers….

After rounds of meetings, the ad campaigns were eventually altered, removing references to bush meat and advising those with symptoms to stay put and call a health worker. “You can survive Ebola!” one of the new posters declared….

The bad news…came like a fusillade. By June 21, Doctors Without Borders had pronounced the epidemic “out of control.”

Yet the W.H.O. waited until Aug. 8 to declare the epidemic “a public health emergency of international concern,” its top threat level. That was two weeks after two American aid workers were infected in Liberia and a man sick with Ebola flew from Liberia to Nigeria….

Today [December 2014], even as infection rates are starting to decline in some areas, there can be more reports of new cases in just two days than were recorded in the first two months of the outbreak.

The governments and organizations that led the response now appear chastened. Many readily acknowledge that they did not devote enough people or resources to the early fight, and that they prematurely lowered their guard….

Even as they continue to battle Ebola across West Africa, the virus hunters find themselves soul-searching about how many lives might have been saved had there been a bigger, more effective initial response. If the epidemic in West Africa has demonstrated anything, it is that a foe as remorseless as Ebola must be met with a killer instinct that is just as unrelenting….

Dr. Rollin of the C.D.C. accepts a share of responsibility. He and other leaders should have recognized how distinct West African culture was, he said. He should have better appreciated how lax the tracing had been, and that the virus’s disappearance from view did not mean that it was gone.

But he also argues that scientists can act only on the facts as they know them, and that much of what happened in West Africa could not have been foreseen, at least not in the fog of an emerging crisis.

“It was an unprecedented outbreak; it never happened before,” he said. “There were a lot of things we didn’t know at that time. No one could have imagined that it would be what we have now.”