Dispatches from the Hot Zone

Months passed before the international community, which viewed the outbreak as a regional issue, stepped in to help. As a New York Times editorial board wrote in June 2014: “The afflicted nations and their neighbors will need to redouble their efforts to contain a virus for which there is neither a cure nor a vaccine.”

Then in a few short weeks over the summer, the outbreak flamed into an epidemic. More than 100 new cases were being reported each week, then more than 300 per week, then 600. During the worst previous Ebola outbreak—the first officially recognized occurrence of the disease, in 1976—a few hundred people died. Now thousands were ill, and infections were burning through families and communities, flaring up in crowded cities and racing ahead of efforts to track or contain them.

There is no cure or treatment for Ebola. At best, IV fluids and supportive care can be used to try to keep patients alive long enough for their immune systems to fight the disease. In the face of a flood of gravely ill patients, however, the region’s under-resourced health care system was quickly overwhelmed. Doctors and nurses were becoming sick.

“It’s sobering to have such a high percentage—65 or 70 percent of the people you are trying to care for—not survive. That is the highest mortality rate of any work I have done.”

Some hospitals and clinics shut down. People were dying in the streets. By early fall, the WHO was projecting the possibility of as many as 1.4 million new cases by the beginning of 2015.

“Past Ebola outbreaks burned themselves out quickly,” says Ingoglia. “This time it was different, and the international community realized we were really behind. We deployed in September and were arriving just as everyone else was.”

Ingoglia planned to spend two weeks in Liberia. He ended up staying for 10.

As head of AmeriCares’ Preparedness, Response and Recovery department, Ingoglia determined his organization’s response to the Ebola crisis. Though AmeriCares was already providing supplies and funding to local partners in West Africa, the decision was made to travel to Liberia in September to better assess the situation there.

“We decided we needed to get information that we could only get on the ground,” Ingoglia says. After many discussions within his organization about the possible risks, it was determined that participation would be voluntary. “It’s the only time I’ve deployed when so many friends and family expressed concern about it.”

Once the team landed in West Africa, Ingoglia held a variety of coordinating meetings and visited existing treatment centers and health care facilities. Ingoglia identified clinics and hospitals that AmeriCares could partner with to provide supplies and funding, and his organization teamed with the International Office for Migration to establish and run three Ebola treatment units with a capacity of 50 patients each.

Arriving several weeks after Ingoglia, Garzon, an emergency medical physician in Davis, Calif., and director of Kaiser Permanente health system’s Global Health Program, deployed with International Medical Corps (IMC) to lead a volunteer team. Before recruiting others, Garzon says he thought hard about the implications: “Could I ethically ask people to step into treatment units and put themselves at risk? I did a lot of reading and had a lot of conversations to under- stand exactly what those risks would be.”

Out of risk assessment came strict protocols. Before setting up two new treatment units in Sierra Leone, Garzon spent several days observing an existing IMC facility in Liberia. His team developed an extensive training program for patient care and treatment protocols—both to protect the health care workers and to boost the numbers of highly skilled responders. By December, the two new treatment units were fully operational, and more than 150 participants had completed the training.

Says Ingoglia, “Doctors and nurses can’t step off the plane and start treating Ebola. People do more training than treating, because the infection-control procedures are very regimented and very precise.”

Entering Ebola wards requires a lengthy and carefully monitored process of suiting up in personal protection (PP) equipment until no skin is showing. The multiple layers of gloves, gowns, hoods, masks, goggles and boots are hot and unwieldy, making it difficult to conduct even simple procedures. Gloves make hands and fingers clumsy, masks fog up, and conversation is muffled. Even more care must be taken in removing PP gear after exiting the ward. But the protocols are inviolable.

“A lot of the medical professionals expressed how difficult it was,” Ingoglia says. “If you’re not in your PP gear, if you haven’t gone through the protocols needed to enter the hot zone, you can be five feet from someone who is crashing, and you can’t do anything.”

For Garzon, the precautions created social isolation unlike anything he’d ever encountered. He’s responded to more than 20 crises in two-plus decades of disaster and human relief work, including the bombing of a federal building in Oklahoma City, hurricanes on the East Coast, floods in California, a tsunami in Sri Lanka, civil unrest in Kenya, famine in Somalia and earthquakes in Haiti, Pakistan and Peru. But last fall was his first infectious-disease outbreak.

“Even in crumbled Port au Prince, after the earthquake, if there was a restaurant still standing we’d go in and grab a meal sometimes,” Garzon says.

But in the Ebola zone, there was no casual engagement with the local community, no visiting of markets or restaurants. Team members stayed one to a room. Shaking hands was off-limits, and there were hand-washing stations everywhere.

“Everyone seems to carry waterless hand sanitizer,” Garzon wrote in his first blog post for Kaiser Permanente in October. “It’s quite possible that my hands have never been as clean as they are now.”

Ingoglia, who traveled to the Philippines in the wake of 2013’s Typhoon Haiyan and, the year before that, joined relief efforts after Superstorm Sandy devastated communities up and down the U.S. East Coast, says that in Liberia, “People were taking your temperature everywhere you went.” Schools were closed. Taxis stopped running. “Then you’d go to a health facility,” he says. “You’d see a big hospital that was essentially closed, or go to a treatment center, and the people would talk about everyone who had died.”

Says Garzon, “It’s sobering to have such a high percentage—65 or 70 percent of the people you are trying to care for—not survive. That is the highest mortality rate of any work I have done.”

“I think if you go into a country in the midst of the worst Ebola epidemic in history and you are not at some level frightened, there is something wrong,” says Richard Besser ’81.

As chief health and medical editor for ABC News, Besser arrived in Liberia in late August, the first correspondent from a major American TV network on the ground anywhere in the hot zone.

He was ideally qualified for this story. Besser had always been interested in global health. As a medical student, he worked at a mission clinic in the Himalayas. He had extensive experience in investigative epidemiology, including working as a “disease detective” at the Centers for Disease Control and Prevention (CDC), which took him to a cholera outbreak in South America, among other assignments. He spent four years running emergency preparedness and response for the CDC and then assumed the role of acting director just before the H1N1 influenza outbreak.

“Ebola in West Africa hit my sweet spot as an outbreak investigator, investigative epidemiologist and TV communicator,” he says. Besser was on the air constantly during the 10 days he initially spent in Liberia. “I was reporting on BBC, on Australian TV, blogging, hosting Facebook and Twitter chats,” he says. “I was on Inside Edition, an entertainment show.”

He demonstrated on camera the lengthy steps required to gown up in personal protective equipment, and he was the first journalist allowed to enter a treatment ward. He spoke of the desperately ill patients he saw there, but also of the ones who had survived. “For me,” Besser says, “it was a chance to make something happening in West Africa real and relevant to people in America.”

Then Ebola came to the U.S. Eric Duncan, a Liberian citizen visiting family in Texas, was the first person ever to be diagnosed with the disease and die on American soil. Two of the nurses who treated Duncan in Dallas developed Ebola soon after. Then physician Craig Spencer was diagnosed in New York City after returning from the hot zone.

When the news of Duncan’s diagnosis broke at the end of September, Besser was in Liberia for a second trip to report on international response efforts. Suddenly, “the focus shifted from Ebola in West Africa to Ebola in America,” he says.

Now Besser was hunting down Duncan’s story, explaining how Ebola traveled from West Africa to the U.S. Even more important, he offered a reassuring voice of calm and reason as Americans, anxiously watching coverage of hazmat-suited cleanup teams entering patients’ apartments in Texas, were introduced to terms like “contact tracing” and “21-day monitoring.”

It was a stark reminder that the world was, indeed, shrinking. “Ebola is a classic case that what happens in very far away places does come home to the U.S.,” says USAID’s Dina Esposito ’83.

By late winter, there were positive signs that the Ebola outbreak was being brought under control. The number of new cases reported each week seemed to be leveling off or declining, there were more treatment centers than only a few months earlier, and schools were reopening.

The crisis, however, was far from over. “You have to get to zero cases,” says Ingoglia. “And then Ebola won’t be over until the entire region is Ebola-free for 42 days.”

It’s entirely possible this outbreak might not be eradicated. But an even bigger risk, Ingoglia says, is that “Ebola gets under control eventually, and the world pats itself on the back and goes home”—even though there is still much more work to be done.

West Africa had long been vulnerable to a humanitarian disaster. The region was poor and under-resourced, with inadequate access to even basic health care. Both Liberia and Sierra Leone were struggling to recover from years-long civil wars.

Today, since the Ebola epidemic, West Africa is even more vulnerable. Economic losses alone are likely to measure in the billions; a January report from the World Bank concluded that the crisis would continue to “cripple” the economies of the three hardest-hit countries: Guinea, Liberia and Sierra Leone. Nearly 22,000 people have fallen ill, and more than 8,500—including some 500 health care workers—have died. Families have been destroyed, communities devastated, countless children orphaned.

Ingoglia says that AmeriCares plans to “evolve its role” in the region, transitioning from crisis intervention to helping communities rebuild and strengthen in the long term. Meanwhile, Esposito’s Office of Food for Peace is supporting immediate hunger relief and helping lay the groundwork to allow the food and market systems to begin functioning again. In the long term, the office will focus on sustaining and building the nutritional health of the region’s people, particularly its children.

In two decades with USAID and an NGO called Pact—often working in Africa—Esposito has witnessed the brutal toll of hunger in the wake of wars, civil unrest, earthquakes and megastorms. Her first major humanitarian crisis was the 1991-92 famine in Somalia. Since joining the Office of Food for Peace as director in 2010, overseeing $2.1 billion annually in food-assistance programming that spans 54 countries, she’s been involved with the Philippines typhoon, conflicts in Syria, South Sudan and the Central African Republic, and a subsequent famine in Somalia.

While famines tend to rivet world attention, she says, chronic hunger and malnutrition set the stage for epidemics like Ebola to wreak havoc. “Malnutrition makes people very vulnerable to other health problems,” says Esposito. “In places like West Africa, which is chronically food insecure, populations are very likely to get ill, and death occurs quickly.”

Better preparing communities to withstand emergencies—by addressing food insecurity, inadequate health care or lack of access to education, clean water and freedom from violence—is the growing focus of humanitarian-relief work in the 21st century.

“Helping communities become more resilient—that is our next big opportunity,” says Garzon. And if there is a lesson to be learned from the first Ebola outbreak to cross oceans, says Ingoglia, it’s this: “We are in a global community, and our fates are all intertwined.”

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