The

West African Ebola Crisis

A retrospective

Chapter 1

Origins

Our story of the Ebola outbreak begins with an 18-month-old boy, Emile Oumanou – the so-called “patient zero” – and a kapok tree.

The tree stands on the outskirts of the village of Meliandou, in Guinea’s densely forested southeastern region. Kapok trees are the giants of the bush; they can grow up to 13ft (4m) in a year, reaching a height of 200ft (60m) and climbing far above the misty forest canopy. As 2013 drew to a close, this particular kapok tree was in bloom, loaded with pungent white and pink flowers. Long-tailed insectivorous bats – “les lolibelos” as locals called them – flocked to the tree, siphoning the juicy red ants and spiders that sucked up the nectar. Children hunted the bats with their hands, as they have done in this part of West Africa for centuries, roasting them over tiny fires like s’mores around a campfire.

Scientists who traced the source of the outbreak believe that it stems from a single zoonotic transmission event, of which Oumanou was the index case. From previous Ebola epidemics in central Africa, researchers knew that animal-to-human transmission is the most likely source of fresh outbreaks, and bats are known to harbor hemorrhagic viruses. At less than two years old, Oumanou was probably too small to have hunted the creatures, but soon after playing in the shade of the kapok tree, he and his four-year-old sister, Philomène, fell sick with what was seen as a mysterious illness. Their mother and grandmother followed; all four of them died.

The sickness, yet to be classed as Ebola, spread through the village, then on to nurses and midwives at a Guéckédou hospital and down to the borders with Liberia and Sierra Leone, spilling south to Conakry, Freetown and Monrovia, east to Lagos, north to Bamako, northwest to Dakar, and by jet to the United States, Spain, the U.K. and Italy.

This is how the story begins. But stories are not science, and we still don’t fully understand how Oumanou contracted Ebola. However, we do know that the true origins of the outbreak likely go back much further.

One study published by German researchers in Annals of Virology in 1982 suggests that Ebola may have been endemic in West Africa in the late 1970s. Six percent of frozen blood samples from 433 Liberian citizens taken in 1978 and 1979 contained antibodies to the Ebola virus, they found. “The results seem to indicate that Liberia has to be included in the Ebola virus endemic zone,” the authors wrote, according to the New York Times. Another three studies published in 1986 showed Ebola antibody prevalence rates of 10.6, 13.4 and 14 percent, respectively, in northwestern Liberia, which suggest, according to the newspaper, “the possibility of what some call ‘sanctuary sites,’ or persistent, if latent, Ebola infection in humans.”

Perhaps, to fully understand the origins of the Ebola outbreak, we need to go even further back. Perhaps the crisis truly began with West Africa’s deep-rooted public mistrust, sparked by centuries of inequality between ruling elites and ordinary citizens. Perhaps it began with the scramble for Africa, with the day that France claimed Guinea, when Britain colonized Sierra Leone, and members of the American Colonization Society landed on Liberia’s shores. Perhaps this is a story about the persistent empathy gap between the rich and the poor, about mankind’s uneasy relationship with our increasingly connected world, or about environmental destruction: timber logging has stolen an estimated 80 percent of Guinea’s forest cover, pushing communities and wild animals to live more closely together.


Chapter 2

Slow to React

Guinea’s Ministry of Health issued its first Ebola alert to the World Health Organization (WHO) on March 13, 2014, and then to Médecins Sans Frontières (MSF). Within ten days, the Institut Pasteur in Lyon, France, had confirmed that the growing outbreak was caused by a hemorrhagic filovirus, later narrowing it down to the Zaire species of the Ebola virus – the deadliest in the filovirus family1, and a sister strain to the clade that had sparked previous outbreaks in D.R. Congo, Gabon and Uganda.

Three days later, with a tally of 86 suspected cases including 60 deaths, the WHO announced a “rapidly evolving” situation with reports of suspected cases in Liberia and Sierra Leone. But it did not endorse any travel or trade restrictions, nor did it press the SOS button by declaring an international health emergency, as Ebola Deeply reported last year in “The Year of Ebola: Diary of an Epidemic.”

By April 2014, there were 18 suspected cases across the border in Liberia, but officials were confident they had the situation in hand. Liberia’s president, Ellen Johnson Sirleaf, said that “while [Ebola] is a concern, there is no need for panic. Be assured that I’m on top of it; I’m getting briefings, I’m in control of it and I feel that the situation is being well managed.” In Sierra Leone, Health Minister Miatta Kargbo told the Awareness Times newspaper the government was “serious about the threat of Ebola” and was “working relentlessly on a number of issues to ensure that the virus does not spill over from Guinea.”

Suddenly and mysteriously, the number of cases began to slow. Between May and June, samples from Sierra Leone tested negative, and Guinea’s authorities began to believe the outbreak was over.

By mid-June, when the total number of deaths in the region rose to 337, authorities began to realize the threat had not gone away. In July, a Liberian named Patrick Sawyer collapsed on arrival at Lagos’s Murtala Muhammed Airport and was eventually diagnosed with Ebola, after inadvertently infecting health workers who treated him.

More troubling signs began to appear. Dr. Sheik Umarr Khan, West Africa’s leading hemorrhagic fever doctor, died later that month from Ebola in Kenema, Sierra Leone. And Dr. Samuel Brisbane, one of Liberia’s most senior physicians, known as “the iron man,” died from the virus in Monrovia. “He had a reputation for dedication, for fighting disease as if it were war,” we reported.

The WHO waited until August 8 to declare the Ebola outbreak “a public health emergency of international concern,” the highest threat level and the first such event since 2009. Leaked emails later published by the Associated Press revealed that the WHO dragged its feet for almost two months after one director declared that it should raise the threat level only as “a last resort.” Dr. Sylvie Briand, head of the WHO’s pandemic and epidemic diseases department, acknowledged to the AP that the organization made mistakes, but said postponing the alert made sense at the time because of potentially catastrophic economic consequences. “What I've seen in general is that for developing countries it’s sort of a death warrant you're signing,” she said.

In a later interview with filmmaker and producer Dan Edge of PBS Frontline’s documentary “Outbreak,” Ebola Deeply covered the importance of tracing the earliest missteps. “Rather than making an experiential on-the-ground film about how the world was trying to contain the outbreak, we wanted to go right back to the beginning and recreate the path of the virus,” Edge said. “The story was one that had already happened; it was the story that nobody was covering back in December 2013, the story of how and why the virus spread so much before the world really did anything.”

Four days after the WHO increased the threat level, it approved the broad use of experimental drugs in treating Ebola, such as the monoclonal antibody treatment ZMapp1, manufactured by Mapp Pharmaceutical. Dr. Kent Brantly and Nancy Writebol, two missionary health workers infected with Ebola while treating patients in Liberia, were among the first to receive it. They were evacuated separately to Emory University Hospital in Atlanta, Georgia. Brantly and Writebol were part of a team from Serving in Mission (SIM) that worked alongside Samaritan’s Purse, the first organization to respond to the Ebola outbreak in Liberia. They both survived, prompting headlines such as the Washington Post’s “Why Do Two White Americans Get the Ebola Serum While Hundreds of Africans Die?”

The dose of ZMapp that the pair shared had, in fact, been intended for Dr. Khan, the Sierra Leonean hemorrhagic fever expert, who had died in Kenema, Sierra Leone, 10 days earlier. Unlike Brantly and Writebol, Khan had been too sick to consent to treatment with ZMapp, and he died while his colleagues weighed the risks, mindful of the most fundamental maxim of medicine: “First, do no harm.”

In Liberia, the WHO’s increased threat level prompted extreme measures, seen by some as over-compensatory. President Johnson Sirleaf reacted, establishing what Canada’s CBC news called “plague villages” in the northern county of Lofa. The Armed Forces of Liberia launched Operation White Shield, designed to establish checkpoints, improve contact tracing and enforce quarantine measures. It backfired dramatically.

Two days after the government placed a “cordon sanitaire” around Monrovia’s West Point neighborhood in a misguided attempt to contain the outbreak, crowds of young protesters tried to surge past the checkpoints, sparking clashes with police. A 16-year-old boy, Shaki Kamara, was fatally shot in the leg after his grandmother, Eva Nah, had sent him out to buy bread and tea.

“Shaki was on the main road at the teashop when the army and police started shooting,” Nah said. “He told one policeman, ‘I know you. Go call my grandma to come and see me.’ But there was no way. No way for me to see the shooting. They took him out of West Point, to John F. Kennedy Hospital. Kennedy didn’t do anything for him. Then they took him to Redemption Hospital. That’s where he died in the night. Gone. No way to come home.”


Chapter 3

Underreported Cases,
Unexpected Consequences

Meanwhile, cases were growing rapidly in Sierra Leone. By August 28, there were 1,026 documented cases of Ebola in the country; 422 people had died. The government was slow to issue warnings; some Sierra Leoneans said they felt that authorities were overconfident they could contain the threat. According to an October 2015 report by the International Crisis Group called “The Politics Behind the Ebola Crisis,” analyses suggest that information at the time was “actively being hidden” and that officials “were downplaying the impact by only reporting confirmed laboratory cases.” An anonymous British diplomat interviewed by International Crisis Group said he believed cases were being underreported by 200 to 300 percent.

When eight healthcare workers and journalists were killed while raising awareness about Ebola in Womé, in southeastern Guinea, in September, Ebola Deeply interviewed President Alpha Condé. “We need to help 12 million Guineans confront their current confusion, their suffering, their reluctance to trust health authorities and their skepticism about the disease, and the strangely dressed strangers wearing frightening space suits seemingly bringing death, removing bodies and asking them not to touch or care for their ailing family members,” Condé said.

The outbreak slid down from Sierra Leone’s provinces to its southern seaside capital, Freetown. At Connaught Hospital, the capital’s most famous hospital, an Ebola triage isolation ward was set up. Doctors reported a severe shortage of protective scrubs, gloves and goggles. Staff were using 200 pairs of gloves a day.

“The health workers are really scared,” Spanish doctor Marta Lado, who was leading the care at the center, told the Washington Post. “This is hard work. We can’t tell them we don’t have enough supplies – to just come to work and later on you’ll have gloves.”

Next door in Liberia, a similar scenario was playing out. Staff at Phebe Hospital in Bong county threatened to strike over a shortage of goggles and gloves, the Wall Street Journal reported.

At the same time, access to resources was hampered by the cancellation of more than a third of all international flights to the affected countries. As NGOs called for a wider humanitarian corridor to be opened, 216 of the 590 monthly flights to Guinea, Liberia and Sierra Leone were canceled. Fearing the spread of the virus farther east, Kenya Airways scrapped its twice-weekly flights to Monrovia and Freetown, locking out some health workers, aid workers and journalists.

Basic health services became the next casualty. In Monrovia, many clinics and hospitals closed their doors, as health workers lacking protection refused to place themselves in harm’s way or risk the further spread of the virus. Asthma attacks, car accidents, diabetes and epilepsy morphed into certain killers. Ebola Deeply spoke to the 17-year-old son of a woman who died in Monrovia from an epileptic fit; his mother was turned away from three hospitals.

Love became the greatest killer of all, as family members of Ebola patients found it impossible not to offer their care. “When I thought I might have Ebola, I told my mom to stay out of my room about five times a day,” said Blackie Jabbah, an ETU laundry worker from Monrovia who suspected he had the virus but ultimately tested negative. “But she didn’t get it. She couldn’t stop taking care of me. One morning I woke up to her gently mopping my head with a facecloth; I had to scream at her to leave.”

In an address to a U.N. meeting on Ebola in New York in September 2014, U.S. president Barack Obama called Ebola “a horrific disease [that is] wiping out entire families. It has turned simple acts of love and comfort and kindness – like holding a sick friend’s hand, or embracing a dying child – into potentially fatal acts.”

During the early days of the outbreak, governments and international organizations also struggled to get their messages across. Early efforts to spread the word about the dangers of Ebola, designed to frighten people into action, inadvertently reinforced a hopeless picture of certain death. Messages ranged from “Ebola is real” to “Ebola spreads quickly and kills!” and “Act Fast! Ebola Kills 90% of Those Infected.”

“At the beginning of the outbreak, one of the messages going out was that Ebola was usually fatal,” said Joseph Howard, director of the Center for Peace and Justice Studies, a Liberian NGO. “Because of that message, some people said, ‘well, if I will surely die, why should I make any effort to seek treatment?’”

Contact tracers reported that communities were confused by the sheer volume of messages. “Each organization thought that they had all the answers, and many of them sent out public messages without harmonizing with the government,” Howard said. It was only when the outbreak escalated even further, he said, “that organizations started finding ways to collaborate more with the government. When you have stiff competition over anything, the value of collaboration disappears.”

The communication gap was most pronounced in Guinea. After the Womé attack, resistance against Ebola responders continued. In a later interview with Ebola Deeply, Timothy La Rose, UNICEF’s communications chief for Guinea, said, “In the beginning, it wasn’t effective to have too many actors come into places that had never seen medical workers in PPE rolling into their villages in large, white vehicles … What the community considers to be foreigners hardly works in these sometimes terrifying situations.” Once the strategy shifted to community involvement, that quickly made a difference, La Rose added.

Senegalese medical doctor Dr. Fatou Mbow – who worked as a community response consultant with Save the Children in Guinea – told us how community resistance was “the key issue.” She also spoke about measures taken by the French military to construct ETUs specifically for health workers, with separated areas for suspected and confirmed cases. At the time, more than 175 health workers had been infected with Ebola in Guinea.

In Sierra Leone, it took months for the government to integrate religious leaders into the conversation on Ebola, and traditional healers – a valuable messaging portal, particularly in rural areas – were left out until much later. Several West African religious leaders told Ebola Deeply that if they had been included earlier in the response, they could have helped to shift perceptions around changing burial practices. “Religion and health cannot be treated as entirely separate issues,” Sheik A.B. Conteh, the president of Sierra Leone's Inter-Religious Council, said.

Communication gaps were often filled by rumor, a legacy of decades of mistrust and false information in the region.

“[During West Africa’s past conflicts], at times the media and authorities reported one thing and the rumour network said something else, and it turned out that the rumours were right,” said Susan Shepler, an associate professor at American University and a specialist on education and conflict in Sierra Leone and Liberia.

In a partnership with On Our Radar, a communication app that highlighted the perspectives of rural Sierra Leoneans, Ebola Deeply shared information about some of these rumors.

In Nigeria, at least two people died and 20 were hospitalized after the rumor spread that drinking saltwater could cure Ebola. Other rumors attributed the outbreak to wells poisoned with formaldehyde and the “Queen of Sheba,” a reincarnated woman from the netherworld thirsty for blood to boost her powers. People often claimed the virus was manufactured by governments and international organizations to make money, while others claimed Ebola was “viral terrorism.” Over time, more finely crafted messages appeared, and organizations such as Internews, Nigeria Health Watch and BBC Media Action worked to help detonate rumors using radio dramas, local journalist training and programs that featured trusted local voices.


Chapter 4

"...As If We Were Snakes"

As the outbreak and the number of deaths continued to grow, so did fear and suspicion. Ebola Deeply reported on the tragic but not unusual story of Finda Fallah and her family, whom we found sleeping rough in New Kru Town, a densely packed Monrovia neighborhood. Five of Fallah’s close relatives had died from Ebola, some at the makeshift M.V. Massaquoi isolation center in West Point. When the center was overrun and looted, there was nowhere for Fallah to go. Harassed, exhausted and afraid, the family camped out on the street.

“We spread lappa [Liberian wax cloth] on the ground and slept on it,” Fallah said. “When the day got clear, we woke up and went to buy food, but people refused to touch our money. As soon as people saw us, they ran away from us, as if we were snakes.” There was nowhere to go, nowhere to hide, nowhere to find treatment. Sometimes, Fallah said, they received food from families living nearby. “But the people threw it at us, like we were trash cans.”

After five days, Fallah and her children were picked up by an ambulance and taken to ELWA 3, MSF’s new treatment facility on the eastern outskirts of Monrovia, where it also became apparent that the crisis was going to overwhelm public health resources.

ELWA 3 eventually grew to a capacity of 250 beds; it was the largest Ebola treatment unit ever built. But it was not big enough. When the Fallah family arrived, there was no room for them. Fallah went to the pharmacy and bought paracetamol – to quell her children’s fevers – and doxycycline, in desperation that a malaria prophylaxis and antibiotic drug might work.

Inside the center, death was a daily occurrence. Every morning, ELWA 3 would open its gate for 30 minutes – enough time to admit a few patients to beds cleared by those who had died overnight. Hundreds of sick people were turned away. Some of them died right outside, on the gravel.

“We had to make the horrendous decision of who we could let into the center,” Rosa Crestani, MSF’s emergency coordinator, said in “Pushed to the Limit and Beyond,” the organization’s mid-outbreak report. “We had two choices: let in those who were earlier in the disease, or take in those who were dying and the most infectious. We went for a balance. There were so many patients and so few staff that the staff had on average only one minute per patient. It was an indescribable horror.”

In the report, MSF admits it was forced to reduce its level of care. The organization lifted its practice of administering I.V. lines, the intravenous hydration practice it had used in past Ebola outbreaks in central Africa. The move prompted sharp debate among the international medical community, and Ebola Deeply reported from ETUs where I.V.s were seen as “silver bullets,” including at Sierra Leone's Hastings ETU. Ebola patients suffering from diarrhea and vomiting can lose up to four cups of electrolyte-rich fluids a day. The resulting hypokalemia – a deficiency of potassium – can affect the heart.

The WHO recommends intravenous hydration for Ebola patients, as does Liberia’s Ministry of Health, which managed the adjacent ELWA 2 treatment unit and did not suspend intravenous hydration. Other organizations that provided Ebola clinical care, including Partners in Health, backed the practice, and an editorial published by the London School of Hygiene and Tropical Medicine noted that “it is likely that many [Ebola] patients die from deficiencies in fluid volume and electrolytes.”

But, overwhelmed by the sheer number of patients, MSF stood by its position. “Admissions were so high that there were not enough staff to safely manage intravenous hydration,” it said in the report. “It was not just a matter of inserting a drip safely, but also of having enough team members to carry out the necessary monitoring, follow-up of fluid hydration for patients and good infection control.”

MSF made a direct plea to the United States to help isolate and treat patients, and Dr. Tom Frieden, the director of the Centers for Disease Control and Prevention (CDC), traveled to ELWA 3 to see the situation for himself.

“I still get goose bumps thinking about it,” Frieden said, in the PBS Frontline documentary “Outbreak.” “I saw a level of devastation I had never seen before. I went into one of the tents and there was a woman lying on the ground. She had beautifully plaited hair, and when I looked more closely, I realized she was dead and the staff were too busy trying to care for the living to even remove her. It was a country essentially in freefall.”

Stephen Kollie Kpoto from West Point never set foot inside ELWA 3, but he brought six of his family members there. Only two ever came out. He told Ebola Deeply that his nine-year-old brother went missing inside. When Kpoto repeatedly asked health workers what had happened to him, they were so overwhelmed they couldn’t locate his medical records. He was never found.

After several days waiting outside ELWA 3, Finda Fallah’s seven-year-old son, Faiyah, was eventually admitted to the treatment center, bleeding from his nose and mouth. He died. Soon after, Fallah herself fell sick, and staff managed to find her a bed.

“The nurse said, ‘Finda, you have Ebola but you will make it,’” Fallah recalled. “I didn’t believe her. But my heart did not burn because I already knew that I was on death. I was not thinking of anything, only that I must just lay down and die.”


Chapter 5

Cut Off, Like an Infected Limb

In September 2014, the CDC released an ominous set of predictions, saying there could be a total of 550,000 cases of Ebola by the following January, or 1.4 million if corrections for underreporting were made. It called the estimates “a warning and a call to action.” CDC Director Dr. Tom Frieden told the New York Times that, “my gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass. But it’s important to understand that it could happen.”

Frieden was right, but the estimates spurred the international community to action – and just in time.

The CDC warning came just as Thomas Eric Duncan, a Liberian citizen, was admitted to an emergency room in Dallas, Texas, with a fever of 103 degrees. He had been visiting his fiancee, Louise Troh, after a 20-year love affair that never quite took hold.

Duncan died on October 8, and two of the nurses who treated him – Nina Pham and Amber Vinson – tested positive for Ebola, sparking fears of an outbreak in Texas. Texas Presbyterian Hospital, where Duncan was treated, later took out a full-page ad in the Dallas Morning Post, apologizing for its lack of preparedness and initially misdiagnosing Duncan.

In an executive summary published on October 16, Ebola Deeply covered the CDC’s decision to tighten guidelines for hospital staff treating suspected Ebola patients following the incident. “Staff treating suspected Ebola patients [must now] wear sealed hoods, shoe coverings and two layers of gloves. A single lapse in procedure can expose a doctor or nurse to infection,” the summary said.

Duncan’s case, the first diagnosed on U.S. shores, may have woken up the country to the situation in West Africa, but it also prompted mass fear and scaremongering media reports. “You Are Not Nearly Scared Enough About Ebola,” screamed a Forbes headline, dwarfing the more on-point op-ed that ran below it by journalist Laurie Garrett. “Could Terrorists Turn Themselves into Ebola Suicide ‘Bombs’?”, asked Britain’s Daily Mail, while a CNN report suggested Ebola might be considered the “ISIS of biological agents.”

By October, when Dr. Craig Spencer – recently returned from an MSF mission to Guinea – had the misfortune to come down with Ebola after going out for meatballs and bowling in New York City, it prompted even more hysteria.

The New York City Office of Emergency Preparedness and Response worked fast, assuring the public there was no need to stay home and running extensive outreach programs in West African communities. But another discrepancy between West Africa and the U.S. had been exposed: North America hadn’t known a major disease outbreak since 1891, when smallpox swept through Chicago.

“These used to be regular kinds of things, even in the West,” Barry Hewlett, a medical anthropologist, told Ebola Deeply in an interview. “We’ve lost some of that experience and accumulated knowledge.”

A quarantine and travel-ban debate raged, and in another executive summary, Ebola Deeply covered the appointment of “Ebola czar” Ron Klain, who worked behind the scenes, shaping the contours of the U.S. response to Ebola and quietly briefing Obama on the approach.

Some states, including New Jersey and Florida, called for aid workers returning from West Africa to undergo mandatory isolation periods, regardless of whether or not they showed symptoms of Ebola (the disease is contagious only once a person is symptomatic). Nurse Kaci Hickox, returning from Sierra Leone, was confined to a tent against her will at New Jersey’s Newark Airport, despite testing negative for Ebola.

While politicians squared off in the U.S. and self-protection took center stage, Nigeria was declared Ebola-free by the WHO, which hailed its extensive contact tracing – comprising visits to more than 18,000 homes – as “world-class epidemiological work.” New cases were emerging – and were swiftly contained – in Mali and Senegal. Mali saw eight cases, including six deaths, while Senegal’s sole patient recovered.

In an interview with Ebola Deeply, Dr. Joanne Liu, MSF’s director, likened the U.S. response to a knee-jerk reaction.

“It’s exactly the same as going to see the doctor, and watching what happens when he taps your knee,” Liu said. “I’m almost begging the world not to shut themselves off from West Africa. Being self-centered is not the way to solve this. Media coverage is feeding imaginations; Ebola is knocking at the door of the Western world, with cases in Spain and the U.S. But the reality is that the situation is absolutely traumatic in West Africa.”

Out of 28,640 cases worldwide, only 11 were ever treated on U.S. soil.


Chapter 6

Silent Heroes

While the international debate continued, West Africa was learning to become its own doctor.

In Guinea, the community organization Tinkisso-Antenna drew upon several years’ experience in hygiene awareness, partnering with UNICEF and Guinea’s Ministry of Health to distribute chlorine buckets to more than 130 medical centers, markets, pharmacies, mosques and churches. Ebola Deeply interviewed Dr. Sakoba Keita, Guinea's National Ebola Response Co-ordinator, about the role of taxi drivers in helping to contain Ebola.

In Sierra Leone’s northern Koinadugu District, young people formed a voluntary taskforce, setting up checkpoints and joining together to buy soap and hand sanitizer with which to man them. Musicians and artists chimed in, expressing the pain of the outbreak in pictures and heartfelt vocals in Krio, Liberian English, Bassa, Kpelle, Pidgin and Susu, to name but a few of the languages in daily circulation in the region.

A group of Sierra Leonean elders, the Port Loko District Indigenes, distributed hundreds of care packages to homes at risk from Ebola transmission. If they delivered food to their doors, they reasoned, residents would have less chance of Ebola exposure in their communities. Power Women 232, a network of young Sierra Leonean women, made up care packages for health workers to boost their spirits amid spiraling stigma. The International Rescue Committee’s Rachel Unkovic spoke to Ebola Deeply about the importance of shared responsibility. “No single action, taken alone, will end the epidemic,” she said.

In Liberia, civil society, youth, women’s and religious groups responded to the crisis by banding together and collaborating in any way they could. Kriterion, a student-run independent arthouse cinema group in Monrovia, put its film screenings on hold and sent its members out into communities, going door-to-door and sharing Ebola messages. As patients were locked out of basic health services, Dr. Mosoka Fallah’s Refuge Place Clinic did all it could to open its doors on the outskirts of Monrovia, offering free basic medical care.

In December 2014 and January 2015, the African Union launched its first ever health mission, sending 855 health workers from countries including D.R. Congo, Ethiopia, Kenya and Nigeria to West Africa. Some were integrated into government health facilities, while others worked as epidemiologists. Among them was Kenyan epidemiologist Joan Karanja, who spoke to Ebola Deeply about a typical day on the ground.

Some individuals took the fight against Ebola into their own hands. Midwives volunteered to set up mobile maternity clinics. Josiah Kormie, a pharmacist in Monrovia’s West Point slum, manned his store day and night, buying a box of personal protective equipment (PPE) from an old colleague and operating a one-man triage operation.

Fatu Kekula, an 18-year-old nursing student, shot to fame after CNN ran a segment on the homemade PPE she used to care for her sick family: gloves made from plastic shopping bags, tied at the wrists with elastic bands. Kekula later won a nursing scholarship to Atlanta’s Emory University. Many more young people, just like her, missed out on public recognition but won something more precious: They saved the lives of family members and friends.

Others battled stigma. Ebola Deeply covered Shoana Solomon’s powerful “I Am a Liberian, Not a Virus” campaign, launched after her nine-year-old daughter was bullied at school in the U.S. “We didn’t start the virus or invent it. On the contrary, it discovered us,” Solomon said.

“The world must know that locals on the ground moved, shifted, stretched, innovated and supported one another to get through one of the most difficult times in Sierra Leone’s history,” said Fatou Wurie, co-founder of The Survivor Dream Project, which works to empower female Ebola survivors in Sierra Leone. “At the local level, there are silent heroes in schools, in government, in healthcare, in business, in the villages and in cities who saved lives. The world must know that we saved ourselves, over and over again through self-determined community mobilization and engagement, through kindness and through our own resilience.”


Chapter 7

The Fever Breaks, But the Pain Goes On

As 2014 drew to a close, Ebola Deeply honored the health workers who had died in the line of duty. “They were doctors, nurses, hospital administrators. One by one, they waged a quiet battle against Ebola in Liberia, Guinea, Sierra Leone, Nigeria and Mali, caring for others at the cost of their own lives,” we wrote.

At times, the pain of Ebola hit close to home. One member of Ebola Deeply’s close team of contributors lost a staggering 70 members of his family in Port Loko, Sierra Leone. “It sounds disturbing, but it’s the reality,” he later wrote. “Ours was a very close family in which people got infected one after the other, dying within weeks.” Another lost his father to Ebola, on Christmas Eve, 2014.

In January 2015, the first signs emerged that the outbreak was slowing, with fewer than 100 weekly cases reported for the first time in seven months. Schools reopened in Guinea in January, and Liberia reopened its borders and lifted a nationwide curfew in place since July. But Sierra Leone remained under a state of emergency; New Year celebrations were canceled, checkpoints remained in place and people stayed home. Samuel Sam-Sumana, the vice president of Sierra Leone, placed himself in quarantine after the death of one of his security personnel. He was the highest-ranking official of any affected country to publicly go into quarantine.

Despite the progress made, real hurdles remained. In an interview with Ebola Deeply, U.N. Ebola mission chief Anthony Banbury spoke about the unpredictable geographical spread of the disease, and voiced concerns about unreliable data. “[Ebola] presents the greatest challenge that I’ve faced,” Banbury said.

By March, the death toll had climbed above 10,000. But encouraged by falling case numbers, public attention began to shift. Eyes were no longer fixed on West Africa. In Sierra Leone and Guinea, however, the horror continued on a smaller scale. The countries’ ministries of health continued to tally weekly cases; six, eleven, an occasional zero. Case numbers similar to those that had sparked hysteria in the U.S. were received with relief in West Africa.

Guinea, in particular, neglected by anglophone media outlets throughout the crisis, continued to struggle to contain the spread of the virus. Case numbers remained more or less constant, without the severe spikes and drops seen in Liberia and Sierra Leone. International Medical Corps (IMC), one of the first Ebola responders in Liberia, launched an operation in Guinea-Bissau, amid fears that the virus would spread across the Guinean border.

Ebola Deeply interviewed Raphael Delhalle, the coordinator of MSF's ETU in Donka, Guinea, who told us that in Guinea, “Ebola is not over. The fight must go on.” And in a “letter from Conakry,” Ebola Deeply’s Guinea correspondent, Tamba Oularé, wrote about how new quarantine measures modeled on those of Sierra Leone were helping to contain cases. Meanwhile, scientists chose to trial the rVSV-ZEBOV Ebola vaccine in Guinea, seeing the country as the final link toward curbing the spread of Ebola in West Africa.

Schools reopened in Sierra Leone, but pregnant girls were excluded from sitting their exams – a move that angered rights groups, particularly since girls and young women had been vulnerable to sexual abuse and economic desperation at the height of the outbreak. Ebola Deeply’s Cinnatus Dumbaya interviewed a high school student who fell pregnant during the outbreak.

Meanwhile, Ebola health workers in Sierra Leone said they had not been paid the hazard wages promised to them by the government. As Newsweek reported, Elizabeth Kabba, a nurse at the badly hit Kenema government hospital – where 37 health workers died from Ebola – said she and many of her colleagues had not received most of the $92 allowance they’d been promised. “We hear about money pouring in, but it is not getting to us,” Kabba told Newsweek. “People are eating the money, people who do not come here. We are pleading nationwide. We have sacrificed our lives.” Some have since received the promised allowances, while others still have not. Dr. Nadia Bhedalia, a physician from Boston who worked on the front lines of Ebola in Kenema, launched a crowdfunding campaign to help fill the gap, and 50 families received gifts of $600 each.

As case numbers settled into the single digits, media coverage began to tackle post-Ebola syndrome. For many of the estimated 17,000 people who survived Ebola in West Africa, the pain has not gone away. The symptoms run from memory loss and joint pain to crippling headaches, hair loss, anorexia, high blood pressure, missed periods, internal bleeding, hearing loss and blindness. According to a study published in the Oxford Journal of Clinical Infectious Diseases, 86 percent of patients monitored after surviving Ebola at one treatment center in Guinea went on to suffer long-lasting joint pain.

In June, the Partnership for Research on Ebola Virus in Liberia (PREVAIL) launched a five-year study of about 7,500 Ebola survivors and family members, co-sponsored by the U.S. National Institutes of Health (NIH) and Liberia’s Ministry of Health. The team, led by Liberia’s Dr. Mosoka Fallah, is drawing blood from survivors at six-month intervals, monitoring and characterizing changes in Ebola antibody levels to gain a deeper understanding of the effects of the virus on survivors. As part of the study, survivors have free access to care. Sierra Leone’s government says that 2,500 of an estimated 4,000 participants have received access to expanded care. MSF is also operating short-term Ebola survivor clinics in Guinea, Liberia and Sierra Leone.

Sullay Kamara, an Ebola survivor, has spent the past 15 years nurturing crops on his small-scale farm on the outskirts of Freetown. He battled the disease for a month at Freetown’s Hastings Ebola treatment center, only to experience severe complications, including internal bleeding, after recovering. “I contracted Ebola last September and was almost losing hope, thinking I was going to die, when the doctors fought and I was saved,” Kamara said. “Months after, just when I thought everything was OK for me, I began experiencing internal bleeding. It’s almost impossible for me to farm on my piece of land, because each time I bend down to dig or plant seeds, blood oozes out of my nose and ears. Even at times when the sun shines heavily and the sky is light, my eyes go dark, and my nose and ears run blood.”

Uveitis, an inflammatory eye condition that causes permanent scarring, is among the most concerning of all post-Ebola complications; if left untreated, it can cause blindness. “The consequences of untreated eye disease are very heavy,” said Mr. Gerry Clare, an ophthalmologist who treated Ebola survivors with MSF in Liberia, in an interview with Ebola Deeply. “If a young person is blinded in Liberia, he or she may be unemployable, unable to continue with their education or become socially excluded. We need to detect eye disease as early as possible in order to treat it, but the pattern is one of under-equipment in almost every ophthalmic facility. Critical equipment is missing from almost every single facility in Liberia. All Ebola survivors should be screened for eye disease at the earliest opportunity.”

Dr. Ian Crozier, an American doctor who contracted Ebola in Guinea last year, lost the vision in one eye as a result of uveitis. “Although some patients present with less severe symptoms, for others it’s too late to change the course of their eye problems,” Crozier told Ebola Deeply. “That’s a tragedy for them, after surviving the virus. Here, going blind is not too far from dying.”

For many of West Africa’s Ebola survivors, the physical fallout from the disease is less frightening than the emotional toll. Patients have described the experience of battling the disease as a protracted, painful brush with death, over and over, for days and days. Most were aware there was no cure. Many did not trust the health workers in PPE who treated them. Few had access to the internet or regular communication with loved ones, for reassurance. Often, the body heals faster than the mind.

Cynthia Tubman, an Ebola ambulance nurse from Paynesville, Liberia, lost her fiance to Ebola. He had joined the ambulance team before her, and had pushed to get her the job, reluctant to tell the supervisor that they were a couple. “I’m still traumatized by the memories,” Tubman said. “The last time I saw him, we were eating together. I had made spaghetti. He put the spoon in his mouth and he called to our little daughter, singing, “Love, come and eat.” Then he put the same spoon in her mouth to feed her. After he got sick, I made all the family take Ebola tests, but I couldn’t tell our supervisor why. I was too embarrassed. How can I ever be free of this shame, of this memory?”

Mohammed Kromah, a 39-year-old survivor also from West Point, lost all three of his children and his wife to Ebola, as well as his job as a salesman. He now drives a tuk-tuk through the clogged arteries of Duala, a busy market neighborhood of Monrovia, for around $3 per day. He said he finds the loneliness almost unbearable. “It’s not good to be alone,” he said, in an interview with Ebola Deeply. “I’d like to get married again, but I don’t have enough money. There’s a fine woman across the border in Guinea who calls me every day, but I can’t afford to propose to her and bring her to Monrovia.”

Liberia has lately adopted the WHO Mental Health Gap Action Programme (mhGAP), which aims to scale up health services for mental, neurological and substance-use disorders. Until now, the capital, Monrovia, has only had one designated mental health treatment center. In partnership with the Liberian government, the Carter Center is also working to train 450 specialized mental health professionals over the next few years.

Sierra Leone still lacks a national mental health framework, and has just a handful of trained psychologists. A coalition that can advocate for patients’ needs has recently launched, but there is a long way to go.

Finda Fallah, who found a bed at MSF’s ELWA 3 Ebola treatment unit after those long days of waiting, survived Ebola. Four of her six children did not. For those who survived, stigma – a word that wasn’t even part of her children’s vocabulary until the outbreak – swept in as a new kind of plague.

Fallah’s nine-year-old niece, Suisanah, was teased by other children after her hair fell out – a common after-effect of Ebola. It’s growing back now, slowly, and Fallah braids it for her, looping colorful bands around it to detract attention from the bald patches.

Sometimes, Fallah says, Suisanah and the other surviving children cry for no reason. “When they start crying, it makes my body weak,” she explains. “Then I start crying, and soon everybody is crying and the only way out is through laughing. Ebola has gone from my body but it is still inside me, making me think about it. It will stay there long life. I know I will always be thinking about it, because my heart got spoiled.”

Like most West Africans living in the grip of fragile health systems, Fallah has always known death. Before Ebola hit, she had lost close family members, but was she was able to seek solace at their tombstones. Ebola, however, also robbed her of that, as Liberia implemented a strict cremation policy. Throughout West Africa, graveyards are a place to leave gifts for late relatives, preserving the link between the living and the dead. We reported from Monrovia on Decoration Day, the time when families usually gather at the graveside of deceased relatives.

“We only got one person’s grave among all the seven people who died from our family,” Fallah said. “We buried my ma, the first person who died. But the other six people were carried away by the Ebola car [ambulance]. That thing can hurt me. I can be thinking about it over and over. I just want to hear somebody say, ‘Oh Finda, come and see your family’s graves.’ Then my heart would cool down small. You can cry, but as long as you are seeing the grave, you can know peace.”

Recently, Fallah’s seven-year-old son, Faiyah, who died from Ebola, appeared to her in a dream, asking for food. “He was standing right beside me,” Fallah said. “He said, ‘Oh mama, I want to eat.’ I said, I will give you rice. But then I woke up and I wanted to cook the food and carry it to him. I wanted to put the food on the grave and say, ‘Faiyah, here is the food you asked for last night.’ But where is the grave? No grave.”


Chapter 8

What We Still Don’t Know

There is still much we don’t understand about Ebola and its after-effects. In October 2015, Scottish Ebola survivor Pauline Cafferkey – who contracted the disease while volunteering as a nurse in Sierra Leone – was hospitalized in isolation when she experienced a meningitis-like syndrome that her doctors believe was a direct consequence of Ebola. As with Ebola, so with the after-effects; it took an outside case to draw the world’s attention to it, but it wasn’t the first time an Ebola survivor had suffered from the clinical signs of meningitis.

According to a study in the Journal of Infectious Diseases, “convulsions or clinical signs of meningitis” were noted among the symptoms of survivors from a 1995 epidemic in D.R. Congo. A child who had recovered from Ebola and was discharged from an MSF treatment center in Liberia last year developed a fever, “tested positive again, and had an encephalopathy,” a brain disorder. Another Liberian survivor, 42-year-old Dennis Khakie, died suddenly in September from convulsions, almost a year after recovering from the disease. It is now known that the viral particles of Ebola can linger in spinal fluid and the eyes, as well as semen and breastmilk, for several months after recovery.

In July 2015, Ebola Deeply visited the Liberia Institute for Biomedical Research (LIBR), where scientists are working to understand more. There, samples from the PREVAIL Ebola natural history study arrive for analysis.

We found Catherine Kpayieli leaning over a sample plate. She extended a bejeweled arm, pinched the pipette and carefully squeezed serum into the tray. Kpayieli is a freshman at Cuttington University in Liberia’s Bong county, where she has just wrapped up her third semester in epidemiology. Like her classmates, Kpayieli chose to major in epidemiology before Ebola came to Liberia. The outbreak changed everything for her. When it escalated, university classes were suspended. Instead, Kpayieli signed up to join the Bong county health team, sharing Ebola prevention messages and encouraging vigilance against the virus in communities. "Ebola encouraged me more in my studies and it broadened my understanding of disease control," she says. "Learning epidemiology is important, but how do you apply it? What's the application? Because of Ebola, now I know."

The researchers at LIBR, most of whom are from the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), were also behind a recent genome sequencing study published in the journal Cell Host & Microbe that suggests most Liberian Ebola virus infections can be traced back to one virus lineage transmitted from Sierra Leone. Genome sequencing is like turning the pages of the virus’ diary; it enables scientists to identify the distance it has traveled through tiny mutations in its genetic makeup. Ebola Deeply interviewed Lawrence Fakoli, Liberia’s first and only geneticist, who said “I'm encouraged by how important this field could be for Liberia.”

Researchers at LIBR have also been spinning samples from a vaccine trial developed by GlaxoSmithKline/NIAID, as well as from an extension of the successful VSV-ZEBOV1 vaccine licensed to NewLink Genetics and Merck. The latter was found to be effective in Guinea; during a ring vaccination1 trial, it had a success rate of 100 percent and it has since been offered to high-risk contacts in Sierra Leone, Liberia and Scotland. In an interview with Ebola Deeply, the vaccine’s co-investigator John-Arne Rottingen said that scientists worked exclusively with a team of Guinean vaccinators.

Together with CDC scientists, LIBR researchers have also led investigations into the cause of two flare-ups of Ebola in Liberia – in June and November, 2015. By testing antibody levels in the close contacts of the most recent cases, they have been able to pinpoint the mother of 15-year-old Nathan Gbotoe, who died in November, as a likely source for the resurgence of the virus. Gbotoe’s mother was never recorded as having survived Ebola, but researchers believe she may have had a low-grade infection and recovered without treatment. She may then have reinfected family members after a surge in replication of lingering Ebola particles in her bodily fluids after giving birth, when her immune system was weakened. Her baby tested positive for Ebola antibodies but was negative for the virus itself.

If the hypothesis proves true, it could have implications for the 17,000 survivors in the region, who already face significant stigma. However, it would likely be seen as a rare but high-consequence event – albeit one that challenges the scope of our existing knowledge about Ebola.


Chapter 9

A Lottery of Death

In April of this year, an editorial appeared in the New York Times, headlined, “Yes, We Were Warned About Ebola.” It was written by Bernice Dahn, Liberia’s Minister of Health, her colleague Vera Mussah, and Cameron Nutt, the Ebola response advisor to Partners in Health’s Dr. Paul Farmer. It drew upon the aforementioned study published in the 1982 edition of Annals of Virology, which found Ebola antibodies in 6 percent of frozen blood samples taken in 1978 and 1979 from more than 400 Liberians.

And yet the outbreak appeared to come as a surprise. As the editorial says, “none of these articles were co-written by a Liberian scientist. The investigators collected their samples, returned home and published the startling results in European medical journals. Few Liberians were then trained in laboratory or epidemiological methods. Even today, downloading one of the papers would cost a physician here $45, about half a week’s salary.”

When we think about saving lives, we think about medicine, equipment, hospital walls, the steady hands of a trained surgeon. We still don’t think as much as we should about the potential of universal access to information, about that dusty old file containing data that could have prepared a region for what was to come. If Ebola was endemic in West Africa in the 1970s, it almost certainly still is.

The WHO declares a country Ebola-free once it has cleared a 42-day period – twice the usual maximum incubation period – with no cases of the virus. Sierra Leone celebrated that watershed moment on November 7. Guinea passed the hurdle on December 29. If there are no new flare-ups in Liberia, it will be re-declared free of Ebola in January. Only then can the countdown begin to declaring West Africa Ebola-free. But as Ebola Deeply reported in an article titled “The Changing Meaning of ‘Ebola-Free’,” we will almost certainly see more flare-ups. With 17,000 Ebola survivors in the region, the chances are high that another wave of survivor-linked infections will emerge. As time passes, those odds will decrease.

“If we have learned anything in this epidemic, it’s that 42 days is not adequate to declare the end of human-to-human transmission,” Dr. Dan Kelly, an Ebola physician who worked extensively in Sierra Leone during the outbreak, told Ebola Deeply. “Eventually, when that happens, we can declare the epidemic of recent history over, but we will see animal-to-human transmission again. We know Ebola is endemic in Sierra Leone, Liberia and Guinea, given that there's an animal reservoir of unknown origin in the region. It will always lie dormant in the areas of the world where prior outbreaks have occurred, and unless we drive the animal into extinction we will never eradicate the disease.”

Science and medicine have made great leaps in treatment possibilities since the Ebola outbreak began. An Ebola vaccine was tested and proven successful in the space of little over a year; a malaria vaccine by GlaxoSmithKline has taken 30 years to clear similar hurdles. But there is no vaccine trial, no experimental drug, no miracle cure to treat some of the deeper root causes of Ebola: inequality, large gaps between elites in power and citizens, and systems that lock out the very poorest people.

On a recent weekend morning in Monrovia, a young graduate asked a group of writers and journalists for feedback on his resume. The graduate had listed a series of office jobs, including an IT internship, but he had omitted a three-month stint working as an Ebola contact tracer in West Point – a job for which he had risked his life, been drenched with buckets of waste water and expletives, and alerted ambulance teams to the sick. “I don’t think the big people would respect that job,” he said, when asked why.

Captain Dr. Baimba Idriss, a Sierra Leonean doctor who treated Ebola patients, told us how he almost considered quitting his job halfway through the outbreak, after his colleague and friend Dr. Dauda Koroma died from the virus. After he was offered in role in a video campaign with Africa United and the actor Idris Elba of “The Wire,” he changed his mind. In the clammy corridors of the 34 Military Hospital ETU, clad in PPE and watching patients die, Dr. Idriss had felt invisible, insecure, impotent. Once he took part in the video, he realized how much his job mattered: because the world had finally told him so.

Ebola responders and survivors from high-income countries have not had to wonder if their lives matter. Hailed as heroes, the world was cheering them on; they became household names while their counterparts in Guinea, Liberia and Sierra Leone worked quietly, without global recognition. American and European Ebola survivors are seen as warriors, fascinating superhuman beings who achieved the impossible. But in the global lottery of zip codes, skin color, connections and status, their odds of coming out alive were simply shorter.


Chapter 10

Postmortem

The special assistant to Liberia’s Ebola response chief, Tolbert G. Nyenswah, signs his emails with a quote by Oscar Wilde. “What seems to us as bitter trials are often blessings in disguise,” it says. In the wake of an outbreak that ripped out 11,315 lives, and has scarred many thousands more, it is cold comfort. What is the blessing? What meaning can we draw from all of this pain? Is there a silver lining?

Governments, international organizations and researchers are tallying lessons learned, compiling reports. There is talk of legacy, of a need to ensure that an outbreak such as Ebola never happens again. In its report, the London School of Hygiene and Tropical Medicine, together with the Lancet, outlines 10 recommendations to strengthen the global system for outbreak prevention and response. These include institutionalizing accountability through an independent commission, and good governance of the WHO through reform and leadership. “Will Ebola Change the Game?” the report asks.

“Given the health system vulnerabilities revealed and exacerbated by the [Ebola] outbreak, the health sector realises it cannot continue with ‘business as usual’ in addressing priorities for the health of Liberians,” according to the Liberian Ministry of Health’s Five Year Investment Plan for Building a Resilient Health System. Hospitals and health centers have received makeovers. Governments are prioritizing essential public health services together with international partners, including in hard-to-reach rural areas, and are working to build core capacities to detect and respond to threats before they escalate. Efforts are underway to strengthen governance and leadership at regional and local levels, and to place stronger emphasis on evidence and community feedback to guide decision-making.

Sierra Leone is developing a health sector recovery plan, and has trained 6,000 health workers in infection control and prevention. Polio and tetanus vaccinations, suspended during Ebola, have resumed, and the country is rolling out an ambitious plan to intensify specialist medical training, including opening a postgraduate medical training institute and a school of health sciences in Makeni. The African Union is also expected to facilitate the deployment of more specialist health professionals.

Donors have earmarked funds for Ebola recovery in Guinea, including 174m euros ($189m) from France for strengthening the health sector, education, water and sanitation. Before the crisis, the country's annual healthcare spend was around $7 per person (2013), among the lowest in the world. The African Union, International Committee of the Red Cross and other organizations have backed hospital and clinic renovations, including in the forest region of Guinea where the outbreak began. Guinea also plans to make investments in the areas of gender, child and social protection. If the African Union dream of an African CDC becomes a reality, Guinea could also benefit from increased access to training and resources for health workers.

While such measures are commendable, significant gaps remain. Many health facilities do not have integrated laboratories or even access to testing for much more than malaria or typhoid; new technologies such as genome sequencing could change that in the future if funding is appropriately allocated. There are gaps in data management and supply chains, knowledge translation, transport issues, and in issuing health worker payments, particularly in Sierra Leone. Despite minor overhauls, all three countries continue to harbor systems that favor personal connections over ability, poor internal communication, low levels of accountability and a lack of motivation among some staff at a policy level.

At the international level, fragmented public health communication risks hampering future disease response efforts and simple solutions have not been applied at scale, nor have lessons been implemented from previous crises such as SARS, H1N1, Haiti’s earthquake and the floods of Bangladesh and Pakistan. The global approach to a crisis remains fragmented; there is a deep need for enhanced government and inter-agency collaboration, harmonized activities, consistent communication and a more inclusive approach that views community responders as the experts that they are.

Accountability is not taken seriously enough. According to the ONE campaign, which launched a tracker to follow donors’ pledges during the Ebola outbreak, “the tools we have for tracking resources in a crisis are not fit-for-purpose ... One of the most basic questions asked during a crisis is ‘how much have donors promised to this effort?’ In the case of Ebola, this question has been incredibly difficult to answer.” For instance, as of April this year, four different figures for German pledges were publicly available on four different sites, varying by almost $100 million, according to the ONE campaign. As long as we cannot track donor pledges, we will never fully know how funds earmarked for the Ebola response were spent.

On the streets of Monrovia, the traffic is heavier than it was before the outbreak hit. There are ambulances, yes, but there are also more white 4WD vehicles tattooed with Ebola response stickers and a growing number of private vehicles at a time when economic growth has tumbled; GDP growth fell to 0.3 percent in 2015 according to the International Monetary Fund.

On a recent afternoon, private cars and motorbikes honked groans of frustration as traffic slowed to a standstill around Monrovia’s Waterside market, close to the entrance of West Point. Inside the slum, yellow tuk-tuks zipped down the uneven streets, while women braided hair in doorways and teenagers lugged bags of coal, for smoking fish, along narrow alleyways. At the end of one such alley, 20-year-old George Kollie sat on a bench outside his home. Someone had written the alphabet in yellow chalk on the corrugated tin walls, and a cloud of flies danced above a wooden table.

In many ways, the interview with Kollie, an Ebola survivor, was unremarkable. He didn’t talk much about trauma or loss. He smiled shyly, chatted about soccer results, and talked about the amount of homework he’s been getting at school. Kollie’s home isn’t connected to Liberia’s national electricity grid, and he studies by the light of a mobile phone. On the side, he sells shoes and shirts by the roadside to fill the family kitty. Kollie doesn’t want to see some great legacy, some kind of epiphany, come out of the Ebola outbreak. He is a student who wants his daily life to improve, to have the same opportunities as others all over the world, to be treated as an equal; he wants to have reliable access to healthcare, to water, to electricity. He wants to play soccer. Kollie’s house is dusty and dark, but high up on the wooden rafters, so small you might just miss it, hangs a simple cloth sign. “BLESSING,” it says, in solid red type.

At least 28,640 people were infected during this Ebola outbreak; a crisis that was downplayed from the beginning, a crisis that could have been prevented had the world respected, and not pitied, West Africa. 11,315 people died. 875 health workers were infected, and 509 of them died. There is no silver lining. Ebola can never be seen as a hidden blessing. But if we look up, beyond ourselves and our postmortem reports, and take this moment to act, to invest in the things that matter – equality, accountability, inclusive relationships, collaboration, trust-building, freedom from stigma, fair access to information, investment in science and medical training on the ground, basic health services, education that goes beyond the didactic, partnerships with community experts, roads built to last – we might have a fighting chance of preventing another public health crisis on the same scale.

Written by Kate Thomas. Editing by Daniel Beaulieu. Art direction by Brock Petrie.

This work is licensed under a Creative Commons BY-NC-SA 4.0 International License.

  1. Glossary

    Zaire Ebolavirus (EBOV)

    One of the five identified strains of Ebola, and the deadliest of the four which are known to cause disease in humans.

    79/100
    Zaire strain
    53/100
    Sudan strain
    27/100
    Bundibugyo strain
    1/100
    Ivory Coast strain
  2. Glossary

    ZMapp

    A pioneering treatment developed by Mapp Biopharmaceutical Inc, made up of a triad of manmade antibodies. It works by binding to the protein of the Ebola virus, lending the body passive immunity. Supplies are limited because the drug is nurtured on the leaves of tobacco plants, and can take weeks to produce.

  3. Glossary

    Ring Vaccination

    Ring vaccination controls an outbreak by vaccinating and monitoring all contacts — the people known to have come into contact with a person confirmed to have been infected with Ebola (a ‘case’) — and contacts of contacts. The idea is to form a buffer of immune individuals to prevent the spread of the disease. The same strategy was used to eradicate smallpox in the 1970s.

  4. Glossary

    VSV-ZEBOV

    An experimental vaccine for protecting against Ebola virus disease that uses an Ebola protein spliced into a vesicular stomatitis virus (VSV). Initial research found that the vaccine was 100% effective in people who received it soon after possible exposure, though more conclusive evidence is needed on its capacity to protect populations through herd immunity. It was developed by scientists at the National Microbiology Laboratory in Winnipeg, Canada.