Hell's Angels: The Doctors and Nurses Who Fought Ebola / Telegraph Magazine
Umaru was the last patient left in the Ebola treatment centre run by Medecins Sans Frontieres at the colonial-era Prince of Wales school in Freetown, Sierra Leone. For a week the 20-year-old hovered on the cusp of death, but never succumbed. The day he was discharged the staff gave him a rock star's send-off. They danced and sang 'Hallelujah MSF' as he walked towards the gates where his parents waited. They hoisted him triumphantly on their shoulders. They hugged him to show he was no longer infectious, and tears flowed. Umaru left with a gift of 90 condoms because the Ebola virus can survive that many days in semen. His departure meant the final score for a centre erected on the school's dusty cricket ground three months earlier was a tie: 83 deaths, 83 survivors.
“It was an insane celebration of human life,” said Sebastian Stein, the young Norwegian engineer who ran the centre. “It's hard to explain how much we hold on to survivors as sources of hope, because most patients die,” added Ella Watson-Stryker, a public health expert from New York and another veteran of MSF's epic year-long battle against the world's deadliest Ebola epidemic.
Three days later, beneath a hot African sun, workmen covered head-to-toe in yellow moon suits, gumboots, gloves and goggles began dismantling the centre. The complex of tents and orange plastic fencing had already been disinfected, but so virulent is this Ebola virus that they were taking no chances. As they took down the triage area, the isolation units and the mortuary, they chucked the planks, sheeting and bin bags full of contaminated equipment on to blazing bonfires.
Stein and Watson-Stryker watched with grim satisfaction as the black smoke billowed upwards. The Ebola epidemic is far from over, but the closing of a centre was nonetheless a landmark that they feared they would never see. “The emotional part of this is very, very strong. We started building this as part of a horrible disease, something we had never seen before in human history, and now its starting to come to an end,” Stein said. “Seeing this feels really good,” Watson-Stryker agreed. “I've seen seven centres going up, and this is the first time I've been there when one came down.”
But they will remember the horrors of the past year for as long as they live. They will recall how for much of that time MSF was practically the only international organisation helping the victims as Ebola rampaged across Guinea, Sierra Leone and Liberia. They will remember how they begged the outside world for help but it did nothing as ten thousand West Africans suffered ghastly, undignified deaths. They will remember how they had to turn the dying away from their overwhelmed treatment centres, how the corpses piled up inside, and how 14 colleagues lost their lives.
“It was surreal in a way I still haven't completely understood. I can literally picture myself standing in a mortuary in a sea of body bags,” Stein said. “We woke up every day, worked as hard as we could, collapsed every night then got up the next day and it was worse,” Watson-Stryker added.
For four decades MSF volunteers have worked in war zones and disaster areas, but probably never in conditions as challenging, harrowing or lonely as this. “It was awful, really really awful, seventh level of hell stuff,” Henry Gray, the British operations manager of MSF's Ebola Response Team, said.
I am sceptical of large international NGOs. I regard them as bloated, bureaucratic and ineffective. I was appalled at the way they used the Haiti earthquake of 2010 to raise vast amounts of money, little of which benefited the victims. But I have long made an exception for MSF, not least because I have repeatedly found their volunteers quietly working in appalling conditions in some of the world's worst hell holes.
Long after most of the other NGOs – and television cameras - had left Haiti, for example, I found MSF in Cite Soleil, reputedly the western hemisphere's worst slum, treating legions of destitute Haitians racked by cholera. In 2012 I found them secretly helping the bombed and traumatised civilians of rebel-held northern Syria when no other major NGO dared operate there.
Founded in 1971 by a group of French doctors outraged by Nigeria's blockade and starvation of the secessionist province of Biafra, and by the international community's silent complicity in that atrocity, its medics have since worked on the front line of countless catastrophes. They have delivered aid and succour to beleaguered civilians during wars, genocides, revolutions, plagues, earthquakes,floods and famines. They have risked their lives in all the world's most notorious 'beauty spots' – Rwanda, the Congo, Somalia, Bosnia, Cambodia, Afghanistan, Iraq, Yemen, Libya, Chechnya, Gaza, the Central African Republic, Darfur, South Sudan, eastern Ukraine. “First in, last out' is their mantra.
MSF has had scores of volunteers killed, wounded and abducted, but curtails a mission only in extreme circumstances - after five of its staff were kidnapped in Syria, the murder of five others in Afghanistan, and multiple killings and abductions in Somalia. In 1999 it won the Nobel peace prize.
It is now the world's largest medical humanitarian organisation, with 23 national associations and an annual budget of well over $1 billion. It has more than 35,000 local and international staff – permanent employees and short-term volunteers, young and old, from around the world - working in more than 60 countries. But it remains more of a grass roots movement than an organisation – a small army of doctors, nurses, engineers and logisticians all deeply committed to the basic principles and ethos of its founders.
Its primary goal is to provide health care to people in need regardless of their race, religion or affiliations. To do that it remains resolutely neutral in any conflict, and fiercely independent of any political, religious or economic powers.
It will talk to the most brutal terrorist organisations and repressive regimes to access the civilian populations they control – the Taleban, Islamic State, Somalia's al-Shabaab, Boko Haram. It insists only that its staff's safety is assured, and that it can deliver aid without interference. It withdrew from North Korea in 1998 because the regime was diverting MSF aid to its supporters, and spurned the US-led humanitarian programme in Afghanistan because it was part of the battle for Afghan hearts and minds.
By the same token MSF medics will treat anyone – wounded al-Qaeda fighters, Syrian soldiers or Sudanese cattle raiders who have attacked villages and slaughtered women and children – provided they leave their weapons outside. It knows full well that they might well resume their killing once they have recovered. “We don't do good or bad. It's not for us to judge,” Paul McMaster, the retired NHS surgeon who chairs MSF UK, insists.
MSF's pursuit of absolute neutrality and independence extends to fund raising. Almost all its income comes from private donors – five million of them. It seldom accepts money from governments, and never from the defence, oil, mining or pharmaceutical industries. Unlike other NGOs, moreover, it does not exploit specific disasters to raise funds for general use, or use emotionally-manipulative images of victims. Six days after the 2004 Asian tsunami it infuriated other NGOs by announcing that it had raised enough.
MSF is lean. The base salary for a field worker is less than £12,000 a year and Joanna Liu, the president, earns a mere £76,000. Even top officials fly economy. Life in the field is so spartan that the MSF house where I stayed in Freetown turned off its generator all day to save money.
MSF is nimble. It can respond swiftly to emergencies because it is not answerable to donor governments or UN agencies. There are few layers of management. Those in charge have all served in the field themselves. “What would take me a month in other organisations I can do in 48 hours with MSF...I don't need approval from seven different levels,” said Watson-Stryker, who had not worked for MSF before the Ebola crisis.
It is also strikingly egalitarian. Anyone can raise issues or address board meetings. MSF is frequently convulsed by passionate internal debates on everything from the naming of the meeting rooms in its new London offices to the dilemmas posed by its second mission - 'temoignage' or 'bearing witness'.
Silence kills, MSF contends. It helped alert the world to the Rwandan genocide, mass rapes in the Congo, the Syrian regime's use of chemical weapons, the torture of Gaddafi supporters by Libya's victorious rebels and much else besides. But 'temoignage' can lead to expulsion, so sometimes MSF does keep mum so it can continue its aid work - and on occasion it has come dangerously close to complicity with repressive regimes.
At times it has pulled its punches - in Ethiopia, Yemen and Myanmar, for example. Most controversially, it agreed not to denounce the Sri Lankan military's brutal treatment of thousands of civilians as it crushed the Tamil Tigers in 2009 – a move that provoked furious arguments and that many MSF staff now regret. “The consensus is we should have been ballsier,” one official said.
MSF wallows in “self-flagellation”. Its employees are “the most difficult, cantankerous, self-critical crowd you could ever work with,” McMaster, MSF's UK chairman, remarked only half in jest. The 23 national associations are all affiliated to one of five largely autonomous operational centres in Brussels, Amsterdam, Geneva, Paris and Amsterdam, and those centres have vigorously disagreed about certain interventions and withdrawals. MSF even has its own think tank – the Centre de Reflexion sur L'Action et les Savoirs Humanitaires or CRASH – which can be savagely critical of its parent body.
But MSF does not just criticise itself. It criticises the rest of the humanitarian aid community, earning itself a reputation for arrogance. Last year, for example, it condemned the “atrophy” of the humanitarian system in a scathing report entitled 'Where Is Everyone?'. It accused other NGOs and UN agencies of risk aversion and shirking emergencies in favour of safer, long-term projects. In the event, the report was amply vindicated by the crisis unfolding in West Africa.
In an industrial zone of northern Brussels MSF has a huge 13,500-square metre warehouse, its shelves stacked floor-to-ceiling with every possible emergency requirement - medicines, blankets, tents, latrines, amputation kits, an inflatable hospital. Early last year it had two Ebola emergency kits in stock. Each was designed for one team to treat 20 patients for 15 days – enough to handle any of the two dozen small outbreaks in remote communities that Africa had suffered since the disease was first identified in 1976.
Then this outbreak erupted in Guinea, and swiftly spread to the capital, Conakry, and to neighbouring Liberia and Sierra Leone. “I've never seen anything like it,” Stefaan Phlips [correct], the warehouse director, said. “The outbreak went from a few tens of cases a day to hundreds. We had to double, triple, quadruple our capacity because the demand was so huge.” Using 30 chartered planes the warehouse has since flown 2,000 tonnes of emergency supplies to 'Ebolaland' including 530,000 protective suits, 130 tonnes of crystallised chlorine, 19,000 body bags, 40 vehicles, 20 marquee-sized tents and five huge incinerators. “This is the biggest emergency operation MSF has run. It was one of the most intensive periods of my life. The whole team was thinking 'if this goes on we will run into the wall',” he said.
But the challenge was nothing compared to that on the ground. Before the outbreak MSF was the only NGO with experience of Ebola, and had a small pool of just 40 medics trained to handle its victims. In late March it realised this was an epidemic of unprecedented magnitude, involving the deadliest strain of Ebola, and raised the alarm. The World Health Organisation accused it of scaremongering - “Don't exaggerate,” its spokesman tweeted. The governments of Guinea aSierra Leone also played it down, with Guinea's president accusing MSF of spreading panic to raise funds.
As MSF rushed staff to West Africa over the following months, some with a bare minimum of training, and as it began urgently building treatment centres in backward countries with rudimentary health care systems still recovering from civil wars, other NGOs evacuated. Local hospitals and clinics were so swamped by cases, and lost so many staff to Ebola (around 500 in total), that most closed. Western governments appeared concerned only to prevent Ebola reaching their populations – an attitude Sebastian Stein described as “fucking horrible”. Every European airline, with the honourable exception of Brussels Airlines, cancelled flights to the stricken region. Even three of MSF's five operational centres held back, leaving the Belgian and Swiss sections to bear the enormous strain.
MSF medics were, in Watson-Stryker's words, “fighting a forest fire with spray bottles”. The organisation begged for help, warning in June that the epidemic was “out of control”. Bart Janssens, MSF's director of operations, said it was “like shouting into a desert...we did not know what words to use that would make the world wake up”.
Not until August 8, shortly after two US doctors contracted Ebola and the death toll topped 1,000, did the WHO finally declare the outbreak a 'public health emergency of international concern'. “The lack of international political will was no longer an option when realisation dawned that Ebola could cross the ocean,” Dr Liu, MSF's president, said.
At the UN General Assembly on September 2 she flayed what she called a “global coalition of inaction”. She demanded the immediate deployment of military biological warfare teams – a highly unusual move for an organisation that normally steers well clear of militaries. She said MSF had treated two-thirds of all those infected with Ebola and was “completely overwhelmed”. MSF rejected a $7 million donation from Australia's government, demanding manpower instead.
Finally, that autumn, the international community began slowly to respond. The US and Britain sent soldiers to build treatment centres – but no-one to man them. “They wanted to help, but not do anything risky – US helicopters would not even transport laboratory samples, or healthy personnel returning from treating patients,” Dr Liu said. Other NGOs arrived, some under pressure from their governments and many trained by MSF in Brussels in what it called the “most extensive knowledge transfer in MSF history”. But by December, for reasons nobody fully understands, the epidemic had started to abate. The new centres never filled. A couple never even opened.
All MSF volunteers receive psychological checks when they return from missions. Janet Hearn, the retired nurse who conducts those checks in London, said the Ebola returnees were “absolutely physically and mentally exhausted”.
It was not just the constant fear of an invisible enemy– the knowledge that one moment of carelessness, one brief exposure to an infected patient, could cost the medics their lives. It was not just the extreme discomfort of working in protective suits in 100 degree temperatures. It was a host of factors that combined to make this possibly the most traumatic mission MSF has ever undertaken.
There were the sheer numbers of patients seeking help, the stream of ambulances arriving with wailing sirens and six or seven victims, some already dead. A huge centre in Monrovia, Liberia's capital, had to turn the least sick away, knowing they would probably infect others. Medics had to say no to fathers who begged them to take a sick child lest that child infect the rest of their family. Some simply died outside the gates.
There was the nature of the deaths – some so sudden that the victims died on the toilet or in the shower, others protracted and agonised with vomiting, diarrhoea and bleeding from orifices and terror on their faces. Most died alone because their families could not, or would not, visit them. They died without any human contact. “The worst thing was not being able to give someone a hug, a human touch, especially the children,” Kate White, an Australian nurse, said.
Medics are trained to save lives, but there is no treatment for Ebola. In no previous crisis had MSF doctors seen so many patients die so fast. Initially more than 70 per cent died, though the survival rate gradually increased. Often all they could do was give them drugs to ease their pain. “Death is part of our world, but not on that scale," Benjamin Black, a young doctor from Manchester, said. "Sometimes your job is to make sure not that someone lives, but that they die comfortably. You can make the difference between a good death and a bad one,”
The medics saw colleagues perish – 28 MSF staff contracted Ebola, including three westerners, and 14 died. They watched entire families die one by one - “We listen to the broken-hearted wails of a woman who has lost the last of her ten children, and then a week later we see her in our triage tent with her small grandson and we watch them die,” Watson-Stryker wrote last September. They had to separate sick children from healthy mothers or vice-versa, and faced some appalling decisions. Should siblings be separated so they did not see each other die? Was it right to evacuate the infected ex-pat doctors and give them experimental drugs while local staff were denied that treatment?
Black was running a clinic for pregnant women suffering from complications when the epidemic reached Sierra Leone. Soon he could not tell which had Ebola, and treating them was extraordinarily dangerous because so many bodily fluids were involved. He isolated all new arrivals while they were tested, and by the time the results came back 24 hours later some who proved Ebola-free had died. Black eventually closed the centre to protect its staff. “It was the hardest decision I've ever had to make,” he said.
The water sanitation teams had it no easier. They had to clean the highly-infectious vomit, blood and excrement off the floors and remove the bodies. The corpses “were unceremoniously sprayed with chlorine, put in a body bag and stored in the mortuary until a burial team came to pick them up. They just dug a hole and shoved them in. There was no imam or pastor, and rarely any family member present,” Stein said.
Such was the pressure that the Sierra Leonian burial teams could take five days to remove the bodies. Stein was loading one decaying corpse into vehicle when lethal bodily fluids poured from the body bag, narrowly missing him. “I was furious that the mortuary was full and I literally had to step over dead people and stack bodies outside, furious at the people who didn't come to collect the dead bodies and furious at the whole fucked-up situation,” he said.
Some locals, particularly in Guinea, were initially hostile, believing Ebola was a western plot to steal blood and organs. They threw rocks at vehicles, looted a treatment centre, refused to let medics take away Ebola victims or corpses. Some locally employed MSF staff were abandoned by their partners and ejected from their homes, their children ostracised. But the ex-pat MSF volunteers were also stigmatised when they went home. Stein's stepfather refused to shake hands, hug or share a toilet with him. Guests shunned a party for Watson-Stryker. White, the nurse, said one of her MSF flatmates moved out when she returned to Amsterdam.
So great was the stress that MSF staff were restricted to stints of four to six weeks rather than several months. A few asked to be repatriated, unable to cope. After a day when seven children were admitted Watson-Stryker declared that she would never return, but she did. “I came back for my colleagues who are tired, heartbroken and angry and need someone to take their place when they are too exhausted to continue,” she wrote. “I came back because of the children dying alone in boxes, and for the elders who, having survived war, now watch their communities being consumed by a virus that has no cure. I came back for the patients who survive. And most of all I came back for our Guinean, Sierra Leonian and Liberian staff who are fighting the long fight with a level of courage and compassion that exceeds anything I have ever seen. If they can keep going for months on end, then I can come back to help them.”
Small wonder that the staff celebrated each survivor, and savoured any remotely uplifting moment. Stein remembers a terrified 22-month-old girl called Iasta who kept escaping from the high risk zone, so the staff built her a cot with high sides. One night she disappeared. Nurses found her asleep on the ground with four grown men, all Ebola victims, sleeping in a ring around her.
Today, in Freetown, the roads are clogged with NGO vehicles. Walls are plastered with Ebola posters. Hand-washing stations and infra-red thermometers are everywhere. Teams rush to quarantine the homes of new victims and trace their recent contacts. MSF, which opened 15 centres, budgeted £80 million, treated more than 8,000 patients and deployed more than 4000 local and international staff during the crisis, is now just a part of that effort.
Before leaving I visited the Kingtom cemetery where, as an additional precaution, all the city's dead are now buried whether Ebola victims or not. It was a bleak place. An area the size of ten football pitches, much of it carved from the adjacent municipal rubbish dump, was covered with fresh graves, each marked by a wooden stick bearing a name and number. White vans delivered a stream of new corpses in body bags, each of which was buried with minimal ceremony by stretcher teams dressed in protective clothing. The scene dramatically illustrated the dreadful scale of the catastrophe - and the consequences of the world's lamentable inaction.
“We did the best we could with what we had, but I'll always wish we could have done more,” Watson-Stryker said. “We knew how to stop Ebola outbreaks. That's the part that breaks your heart. We knew how, but we just weren't able to do it.”