As the deadly infection rages through West Africa, Harvard Chan faculty, students, and alumni are waging a counterattack: on the ground, in the lab, on the humanitarian front, and in the political sphere. A special report by Harvard Public Health editor Madeline Drexler.
December 10, 2014 – The first Ebola case that Mosoka Fallah saw with his own eyes was in early April 2014. The woman had come from Lofa County, in northwestern Liberia. She had cared for her brother, who died of the infection. Sickened herself, she took a taxi bound for Monrovia, the capital. She stayed one night in a crowded squatters’ district named Chicken Soup Factory, left the next morning, and died. Miraculously, no one else was infected.
Fallah, MPH ’12, saw his second case on June 27. A young woman—the only surviving member of a family of seven who had died from Ebola—was brought from neighboring Sierra Leone by her uncle. They made their way to New Kru Town, a coastal suburb of Monrovia. She died and was buried by her relatives—five of whom contracted Ebola and also died. The woman’s infection spread to hospital staffers, who died. By now, Fallah had read extensively about the highly transmissible and fatal infection. He knew that the country’s defenses were weak—the bureaucracy slow and resources meager—and that health workers were chasing outbreaks instead of anticipating them.
In interviews and in gripping emails chronicling the Ebola epidemic as it unfolds—“[t]his is the perfect storm for an exponential increase in the transmission of the disease,” he wrote on August 15—he warned that the new clusters of Ebola would not be contained as readily as the first case in April. By the end of August, Liberia reported 225 confirmed deaths. Soon after, Fallah lost count of the dead and dying.
“I was telling people back in August: ‘It’s going to engulf this country. We could not operate like a normal mood. We had to operate from the framework of extreme emergency,’” he said in an interview with Harvard Public Health in early November. “But many persons weren’t listening.”
“We are in trouble.”
August 12 was a day of ceaseless rain. Fallah and his fellow workers were toiling in the impoverished Monrovia township of West Point. “We pulled six bodies from houses that day.” At the time, it took two or three days for ambulances or burial crews to remove the dead. “We picked up a dead person, and I saw this lady crawl out of the house, vomiting and toileting blood all around. West Point is very congested, no sanitation,” he recalled.
He phoned his boss, the assistant minister for vital statistics in Liberia’s Ministry of Health and Social Welfare. “We are in trouble,” Fallah said. “Ebola has come to West Point.’”
Luckily, Fallah had become a trusted presence among local tribal chiefs and community leaders. He himself had grown up in West Point and in Chicken Soup Factory. His secret to earning trust was no secret.
“Let them see you as part of them” he said. “When I entered West Point, I never stayed in my car. I got out and I walked and I met the leaders. I walked with them in the houses and in between the houses. I never touched them—it was an epidemic, and I kept my distance. But I wasn’t bringing this big Harvard degree to them. I wasn’t telling them that I knew it all. I let the leaders make decisions and I guided them and followed them.” Even when he was approached by a criminal gang for a handout—“It was about $1 U.S.”—he was showered with praise. “One of them said to me, ‘You are a true friend of West Point. You never abandoned us.’”
On that drenching August day when Ebola surfaced in West Point, Fallah discreetly approached some of the leaders and carried on whispered conversations in the corner of a community room. He pressed for details about the outbreak. “It became apparent that what we were seeing was the tip of the iceberg. There had been secret burials. The people had been sworn to secrecy.”
Concerned that keeping the sick in densely crowded West Point would spark an uncontrollable explosion of the deadly disease, Fallah made a decision that, in retrospect, he considers a mistake: He convinced his boss at the health ministry of the need for a holding center for Ebola-sickened residents. “The people did not understand. They said we were trying to bring Ebola to West Point.” After a mob stormed the center, the government ordered an army-enforced quarantine of the entire township. A series of misunderstandings led to violent protests.
Fallah once again acted as a trusted go-between, negotiating a de-quarantine and organizing a homegrown active case finding program that has since become the national model of local surveillance during the crisis. To his amazement, communities that once fearfully denied Ebola are now coalescing around the crisis and organizing task forces and awareness teams.
“The enemy is the person you love most.”
An epidemiologist and immunologist, Fallah came to the School in 2011 to study global health, with a concentration in infectious disease epidemiology. He focused on maternal, newborn, and child health in the slums of Monrovia. After earning his MPH, Fallah worked at Massachusetts General Hospital, studying the psychological ravages that followed Liberia’s two recent civil wars.
How does the trauma of the Ebola epidemic compare? “The pain is not too visible yet,” he explains, “but people are in shock. They are not going to even know where to start from. During the civil war, there were front lines, there were enemies.
“The thing about this epidemic that is even more deadly than the civil war is that the enemy is the person you love the most. The enemy can well be your mom or your husband or your children. How do we explain a family that has lost everyone except a single child? Will there be hopelessness? Fear? Aggression? Paranoia and psychosis? I don’t know the answer.”
“Am I losing my humanity?”
Nor does he know how he himself has survived psychologically. “On August 29th, l lost my sister in Ghana. She had a lung illness. I’m a very emotional person. The morning my sister died and I got the call, I was just about to go to West Point.” He asked another sister to inform their mother, and he drove to West Point, as he did every day, with the firm resolve to stop Ebola. “I didn’t cry or break down.”
When he returned home that night, he fell into bed exhausted. He remembers asking himself: “Am I losing my touch of humanity? I just lost my sister but I’m not crying. Is it because there’s so much death and dying around me? Is it that I’m in survival mode?”
He does cry when a baby dies. “It breaks my heart. So much innocence. They haven’t even started life and Ebola has already taken it away.”
A Refuge for Women and Children
In 2013, before the Ebola crisis, Fallah was hired by Indiana University for a USAID project to develop a public health certificate program for mid-level health workers. After nine-and-a-half years of study in the U.S., he returned home that January to launch the program. Its mission was to train midwives and nurses in techniques that would reduce maternal and child mortality. Fallah also used the opportunity to construct a clinic catering to women and children in Monrovia’s slums. Refuge Place clinic began operation in early June 2014. A few weeks later, Ebola struck. The newly minted public health students were dispatched to the center of the crisis. But as the epidemic mounted and medical staffs around the country were becoming infected, Fallah decided to shutter Refuge Place.
By the fall, he had changed his mind. “I realized that pregnant women and children were still dying of common diseases—malaria, diarrhea, acute respiratory infections. They didn’t have anywhere to go.” And so, after rigorously training his staff in infection control and prevention, Fallah reopened Refuge Place in early October as a medical haven for pregnant women and children under 5, with all services free of charge.
“Not all of the sick have Ebola,” Fallah said. “It’s a complex paradox. On the one hand, you’re trying to stay alive in an epidemic. On the other hand, my fear is that we’re going to see a great increase in deaths from common, preventable diseases.”
Indeed, in early November, when he spoke to Harvard Public Health, a national lab in Monrovia had found that among the clinical samples it was testing, only 36 percent tested positive for Ebola; the rest were familiar infections endemic in the country. Today, said Fallah, there is a dire need for ambulances to transport to treatment these non-Ebola sufferers who in normal circumstances could easily be saved.
What finally compelled Fallah to reopen Refuge Place was a horrifying scene he witnessed in the capital. “A pregnant woman was denied care because she could not afford the $300 for delivery. While she was walking from the private hospital that turned her away, she gave birth to twins in the street. In the street. A guy helped her deliver—he had to wear plastic bags. Then we arrived on the scene. That is fundamentally unfair: that one person should have access to health care in the middle of an epidemic and a pregnant woman should be condemned to die. I gave the family $20 to charter a taxi to the next hospital.”
Taming the Epidemic
At times, Fallah is cynical about the world’s tardy notice of the public health wildfire that has ravaged West Africa. “Not until an American doctor became infected—not until it became an international threat—did they mount an effective response. If we had invested one-tenth of what we’re investing now back in July, when there were just a few hundred cases, this epidemic could have been stopped.” By early November, Fallah estimates, the toll was likely 5,000–6,000 in Liberia alone—far more than the official estimates.
Today, the epidemic curve seems to be flattening. New cases are diminishing. Fallah worries that the success wrought by the all-out campaign that he has helped lead will lull Liberians into relaxing their vigilance. “The last mile,” he warned, “is when you must intensify your intervention.”
What will it take to extinguish the epidemic? Perfect contact tracing. Right now, said Fallah, health workers have been able to directly meet and follow some 60–70 percent of the contacts of infected people. Working with the U.S. Centers for Disease Control and Prevention, he and his colleagues are synthesizing treatment data, contact data, and GPS information from body retrievals and burials to sharply delineate the changing contours of the epidemic.
Every night, the data are analyzed at the Ministry of Health. Every morning, thousands of volunteers are handed address lists for known contacts of the infected. When they find these contacts, they ask them to go into 21-day quarantine, with the promise that neighbors will bring food and water. Other volunteers conduct active contact tracing, moving house to house to ferret out cases that haven’t come to light.
Fallah’s goal is to train 6,000 active case finders throughout Liberia. “If we can find 100 percent of the contacts, we can break the transmission.”
Years from now, what does Mosoka Fallah see in his mind’s eye when he looks back on Liberia’s Ebola nightmare? He answers in the present tense, as if he can’t imagine that this bad dream will recede in memory. “All of the unsung heroes. Some of them are ordinary people, uneducated, poor. The guys who track cases. The guys who pick up the phone and give us updates every day. The guys who stand by me. There are many good people in Liberia.”
Bringing a Harvard Chan Education to an Ebola Epidemic
As he helps direct Liberia’s emergency response to Ebola, Mosoka Fallah’s education at the School has frequently informed his work. “First of all, we learned a perspective of social justice. That was drilled in our heads over and over—whether it was health-systems strengthening, infectious disease, ecology. Richard Cash—what a great instructor, looking at health from a human rights perspective. These are issues that really got deep in my heart.”
In classes with the late Marc Roberts, professor of political economy emeritus, and Daniel Wikler, the Mary B. Saltonstall Professor of Population Ethics, Fallah learned the terms “natural lottery” and “social lottery.” “Maybe I have the IQ and my IQ allowed me to go to Harvard. Maybe because of that I have a new social class and social connections. It’s likely that I will have some opportunities in life because of the friends I make.
“But there are those who may not be as fortunate. Those in West Point—for three generations they have been there. Maybe their mom and dad are poor peddlers. In the grand scheme of things, they may not have won the lottery. Do we victimize them? Do we create a health care system that only caters to guys like me? During an epidemic, nobody shouldn’t have access to health care.”
In the Lab: Tracking a New Outbreak
The Ebola epidemic in Sierra Leone was sparked in late May 2014, when 13 women prepared for burial the body of a traditional healer who had been working in neighboring Guinea. Pardis Sabeti, associate professor in the Department of Immunology and Infectious Diseases at Harvard T.H. Chan School of Public Health, and colleagues traced the path of the lethal virus from the healer to her burial attendants (see graphic below). The Sabeti lab has also been tracking key genetic mutations as the virus spreads. During the course of the outbreak, Sabeti has lost five African colleagues to Ebola infection. Last August, she told the Boston Globe: “We wake up, we learn some news, we bawl our eyes out, and we try to figure out what we can do.”