EBOLA HITS HOME
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.
—Albert Camus, The Plague, 1947
Outbreaks are inevitable. Pandemics are optional.
—Dr. Larry Brilliant on Ebola, 2014
The Twenty-Fifth Epidemic?
This is the first time the disease has been detected in West Africa, and the outbreak has now spread to the American and European continents.
—World Health Organization, October 24, 2014
Serologic results provide evidence that ebolaviruses are circulating and infecting humans in West Africa. This extends the ebolavirus geographic region to Sierra Leone and the surrounding region.
—Dr. Humarr Khan and colleagues, in reference to blood samples collected in eastern Sierra Leone over the decade prior to 2014
The regions usually affected by the Ebola virus—in or near the receding forests of central and eastern Africa—have long been the theater of explosive if uncharted epidemics. When these plagues kill, as they’re apt to do in a medical desert, surviving family don’t receive any official report of cause of death. No labs or health systems have tracked the disease while treating it; nobody can say for sure what the culprit pathogens are. To echo Albert Camus, nobody knows what’s come crashing down on them. Survivors and their families come up with their own explanations. So do epidemiologists, medical journalists, and public-health authorities of every stripe.
West Africa’s Ebola outbreak, the largest in recorded history, is widely held by expert opinion to have its origins in the eastern reaches of Guinea, Liberia, and Sierra Leone, which converge in a bit of turf known as the Kissi Triangle. For centuries this “trizone” region—in which the virus, we’re assured repeatedly, was unknown until 2013—was largely covered by a mosaic of forest and savannah, tended by a large and mobile population of farmers, traders, and hunters of diverse origins. (Guineans often call them forestiers.) In recent decades, commercial logging, small-scale charcoal production, mining, and war have greatly reduced the forest and its wildlife. From this disrupted real estate, Ebola snaked its tendrils into several other nations. But it was in Guinea, Liberia, and Sierra Leone, and really only there, that the epidemic blanketed the land.
Why? All documented Ebola outbreaks—the World Health Organization (WHO) pronounced this one the world’s twenty-fifth—have been registered in settings of profound poverty. By most criteria, that’s an apt description of what one finds in Guinea, Liberia, and Sierra Leone. But in terms of gross domestic product per capita, these three countries were growing faster than the United States or Europe throughout the decade prior to the outbreak. Measured only by this tired calculus, Sierra Leone boasted the world’s highest rate of economic growth in 2013.1
The engines of this specious boom remain the extractive industries—logging, along with the quest for oil, minerals, precious metals, diamonds, and rubber latex. But profits from these industries rarely remained in the vicinity, and they were almost never invested in public goods, such as robust health systems able to contain epidemics—or to flatten their curves and surges—while caring for the afflicted. Maybe in Norway, but not in West Africa: For all their natural wealth, Guinea, Liberia, and Sierra Leone rank among the most medically impoverished nations on the face of the earth; for all their rainfall, their citizens are stranded in the medical desert. In this desert, a diagnosis—and answers to the who-when-why-how questions—is more likely to come from a diviner or other traditional healer than from a laboratory, or is produced by authorities well after the fact and on a basis other than firsthand observations. This raises a corollary question. When an epidemic occurs in a public-health desert, who decides when and where it begins or ends?
To understand the how and the why of the West African Ebola epidemic, you have to turn first to the specifics of who, when, and where. Since Ebola is a zoonosis, a disease caused by a pathogen able to leap from its natural hosts to humans, the people posing these questions tend to search for an outbreak’s first human victims. Epidemiologists, health authorities, and journalists look for “Patient Zero” and seek to trace subsequent paths of spread. But Ebola origin stories can rarely be confirmed, since most stricken by Ebola in the clinical desert die. Blood samples aren’t often collected prior to death, nor are postmortem studies performed.
Here, with ready acknowledgment of uncertainty, is the dominant origin story of the Ebola epidemic believed to have begun at the close of 2013 in southeastern Guinea.
* * *
In early December, or maybe a couple of weeks later, a toddler named Émile fell ill in the tiny upland village of Meliandou.2 He’s said to be one year old in some accounts, in others two, and usually somewhere in between. Émile’s mother, then heavily pregnant, noted the boy was running a fever and had diarrhea. (In some versions of the story, this was black or bloody stool.) Although such signs and symptoms aren’t rare occurrences in Meliandou, she was worried enough to move back to her own mother’s house in the same village.
Recollections and reports are discrepant regarding not only Émile’s age and symptoms but also what care he received, and from whom. One takedown of Meliandou origin stories insists that he was diagnosed with malaria by a “doctor” in the village’s “community health clinic,” but Guinean villages with a few hundred residents don’t boast any of these, not in the sense implied by the terms.3 The family’s interventions, whatever they may have been, were in vain. When Émile died—on December 6 in early versions of the story and on December 28 in later ones—no red flags were raised beyond the village or beyond its families, which counted many scattered in towns and cities across the region. It’s doubtful that health authorities in nearby Guéckédou, the district capital, were alerted. A toddler’s death, exceedingly rare in the wealthier parts of the world, occurs all too often in rural Guinea, where malaria is the most common culprit. Nor was any official fuss made when Émile’s four-year-old sister—sometimes said to be three, which would imply unusual fecundity if the boy was two and their mother eight months pregnant—perished eight days after he did.
Their mother was the next to mount a fever. In her case, it was accompanied by signs of early labor, including passage of blood clots. (Other iterations assert she’d received an injection for hip pain, which triggered hemorrhage from the injection site.) In the course of a stillbirth, the young woman began bleeding out. Her husband desperately sought help from a “village midwife,” who wasn’t formally trained as a midwife and certainly not supplied with the tools of the trade—gloves, aprons, sutures, pads and dressings, sterile razors, clamps, and blood for such emergencies. She and another birth attendant, who were related to Émile by marriage or blood, did their best. But Émile’s mother died that night in her mother’s home, or, according to some accounts, her own.
As if these losses weren’t enough to make any family feel cursed, Émile’s maternal grandmother was soon sick with fever, nausea, and abdominal pain. According to a report bearing the imprimatur of the World Health Organization, she hedged any bets on curses and other supernatural etiologies by seeking care in Guéckédou, where she knew a nurse at its public hospital. Guéckédou, too, is all over the map in these origin stories: sometimes it’s a forest village, sometimes a town, sometimes a city. It’s in fact a small city and the capital of the district of the same name, and its ragged edges extend to a few miles away from an unpaved track leading to Meliandou. The village can be reached, as is clear from photographs illustrating scores of articles and reports about Patient Zero, by jeeps and the like.
Even critically ill or injured villagers didn’t have ready access to such transport. When they made it to hospitals, it was on foot, by motorcycle taxi, or on handcrafted stretchers carried by kin. Émile’s grandmother took a moto taxi to Guéckédou’s district hospital, which, according to a hand-lettered billboard at the facility, had benefited from a “health-systems strengthening program” funded by a large international aid agency. But said health system hadn’t been strengthened nearly enough: After a harried and rapid exchange, which didn’t include more than a cursory examination, the forty-six-year-old grandmother was judged to have malaria or some other infection common on the outskirts of the forest. She went home and died there in mid-January 2014. Other kin were sickened at about the same time, and several perished.
The decimation of this extended family and several others was attributed to Ebola by a retrospective study of transmission chains leading from subsequent patients back to Meliandou, and back to Émile. But since Ebola is a zoonosis, another species must be implicated in the fevered quest for Patient Zero. Bats are likely culprits, and there were plenty of those flitting about Meliandou. The ones alleged (by some experts) to be Ebola’s natural hosts have lovely names: Franquet’s epauletted fruit bat, the hammer-headed fruit bat, the little-collared fruit bat, the little free-tailed bat. Generous helpings of speculation prop up the assertion that Émile had fallen ill a few days after eating a bat-gnawed mango, or maybe a plum, or the fruit of a palm tree well liked by bats.
Some experts reported that Meliandou’s toddlers were pleased to snack on bats as well as fruit. The journalist Laurie Garrett offered up the following scenario (starring yet another bat species with different dietary habits) in the now-dominant origin story. It draws on scientific authority of the German variety:
At the edge of a great rainforest where Guinea, Liberia, and Sierra Leone meet, a two-year-old boy named Émile crawled about a water-soaked tree stump with other toddlers and discovered a bunch of little, furry winged creatures. Grabbing at them and poking them with a stick, Émile reportedly played with the nest of lolibelo—the name locals use to describe musk-smelling, dark gray bats with bodies about the size of a child’s open hand. Many months later, a team of German anthropologists and biologists would visit the Guinean village of Meliandou and determine that Émile’s lolibelo were Angolan free-tailed bats or perhaps members of a similar species of mammal found across most of sub-Saharan Africa. Surviving children in the village told visiting scientists and reporters that youngsters had smoked lolibelo out of the tree, filled up sacks with the flying mammals, and eaten them.4
One problem with this sort of scientific authority is that the Germans’ eight days in Meliandou didn’t turn up much in the way of evidence to support such an origin story. None of the sacks of bats they sampled—including eighty-eight captured in the village—had evidence of Ebola infection.5
More classically defined monkey business also shows up in many Ebola origin stories. Nonhuman primates are sickened or killed by the viral strains that sicken humans and thus unlikely to be natural hosts, but they reliably play at least a part in these tales. As regards the spillover event in Guinea, the German team and local ones were unable to document a recent die-off of nonhuman primates or other fauna, as had been described during prior Ebola outbreaks in the Congo. None of this tempered the need for an authoritative origin story—and a Patient Zero—in the absence of solid evidence. That’s why some of these stories allege that villagers in Meliandou kept monkeys as pets or, in another trending version, that Émile’s family was among those whose diets included monkey: even if the toddler was too young to chew on monkey meat, he might have been splashed by blood-spatter as it was being butchered or prepared for dinner.
More free-range speculation in the race to identify Patient Zero posited that Émile had received an injection with an unsterilized syringe. This marked an unconventional twist in an Ebola origin story, since he would no longer be a contender for the title unless he shared needles with another species. As babies are unlikely to hunt, gather, dress, smoke out, or poke at animals, or to eat them uncooked, Émile makes a less compelling Patient Zero than might older kids in Meliandou. His grieving father—likely weary of interrogation, impoverished by funeral expenses, and having concluded his family was cursed by more than German scientists and journalists—later said as much: “It wasn’t Émile that started it. Émile was too young to eat bats, and he was too small to be playing in the bush all on his own. He was always with his mother.”6
* * *
A boy dies of an unknown fever, followed by his mother and other close kin: this is among the oldest, saddest, and most common stories of the fever coast and what remains of its brooding inland forest. In the year or so that followed, close to a third of Meliandou’s inhabitants died, were sickened, or fled. But the tragedies in Meliandou, though investigated by local authorities and reported to national ones, did not announce the Ebola nightmare. That happened after the region’s professional caregivers began to sicken and die.
Upper West Africa
Although Émile’s immediate family was decimated within a month or two of his demise, the events in Meliandou might have gone unnoticed beyond Guinea’s forest districts, or forgotten as quickly as his grandmother’s miserable visit to a miserable outpatient clinic in a miserably staffed and stocked hospital. No international alarms were sounded when other kin and neighbors—those who’d cared for or cleaned up after the sick, or buried them—were felled in the first weeks of the new year. Casualties included the birth attendants who’d assisted Émile’s mother the night she died, as well as another of their peers. By then, however, Guinea’s local health authorities had taken note.
Shortly after Émile’s grandmother perished, a doctor in a town not far away saw three patients die in the span of two days, laid low by diarrhea, vomiting, and severe dehydration. He suspected cholera. When the physician realized all three were from Meliandou, which counted fewer than forty households, he reported these deaths to his superiors in Guéckédou. They in turn reported them to provincial authorities in N’Zérékoré, another city in the Kissi Triangle. Along with Macenta, these cities and their surrounding districts had received the great majority of war refugees during the early years of the civil wars that wracked Liberia and Sierra Leone; not long before the Ebola outbreak, there were more Liberian refugees than native forestiers living in Guinea’s patch of the triangle. Health authorities in the Kissi Triangle were, in other words, accustomed to responding to transnational epidemics in the region.
When Guéckédou’s health authorities kicked the report up to Conakry, the capital of Guinea, they also dispatched a small team to investigate the rash of unexplained febrile deaths in Meliandou and among folks from or visiting it. Members of this team knew there were clinical reasons to doubt the diagnosis of cholera: most deaths had followed high fevers, which would be an atypical presentation of the disease. But as cholera outbreaks weren’t rare in the region, the team from Guéckédou settled on it as the likely culprit. At least its members allowed they were far from sure—a rare modesty in the crafting of outbreak narratives.
* * *
Medical modesty is warranted in considering outbreaks of Ebola, since the disease is spread by acts of caregiving: it’s when a patient or health professional is confirmed to have been stricken with Ebola within a health facility that the international containment whistle usually blows. That’s what came to pass in Guinea. The alarm was sounded not long after the sudden death of a nurse within another forest-district hospital was revealed as a link in the chain leading to Meliandou.
This was the same nurse, a young man, who saw Émile’s grandmother in Guéckédou’s hospital. In early February 2014, he fell ill with fever, muscle aches, and profound weakness. When diarrhea and nausea kicked in, he sought care from a doctor friend living in the neighboring district of Macenta. By the time he reached its capital, the city of Macenta, the nurse was critically ill. The doctor urged him to report at once to the district hospital for laboratory tests. But as it was late and the lab was closed, he opened up his home to the stricken man, who shared a room with the doctor’s son. It must have been a sleepless night: the nurse retched uncontrollably, and his diarrhea did not let up. The next day—February 10 in most reports—he died in the waiting room of the hospital’s laboratory.
Copyright © 2020 by Paul Farmer