A Stabbing, A Possible Ebola Outbreak, And A 'Time Bomb' In Liberia, a team of epidemiologists have to delay a criminal investigation, look the other way on illegal drug use and build trust to stop an outbreak of Ebola.
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A Stabbing, A Possible Ebola Outbreak, And A 'Time Bomb'

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A Stabbing, A Possible Ebola Outbreak, And A 'Time Bomb'

A Stabbing, A Possible Ebola Outbreak, And A 'Time Bomb'

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SHANKAR VEDANTAM, HOST:

This is HIDDEN BRAIN. I'm Shankar Vedantam.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

VEDANTAM: In 1950, before he directed the film "On The Waterfront," Elia Kazan made another dramatic thriller, a movie called "Panic In The Streets." There's a reason you probably haven't heard of it. It isn't a great movie.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

UNIDENTIFIED ACTOR: Herewith recorded is the story of a silent, savage menace. The events, incidents and emotions of the people who were a part of it who found time running out as they looked into the face of mortal peril.

VEDANTAM: The film tells the fictional story of a murder in New Orleans. When the police investigate, they find the victim suffered from a deadly infectious disease, a version of the plague. Public health officials believe the killers may have contracted the disease as they carried the victim's body away. What follows is a race to track down the criminals and halt an epidemic, a collision of law enforcement and public health.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

RICHARD WIDMARK: (As Lt. Cmdr. Clinton Clint Reed M.D.) If the killer is incubating pneumonic plague, he can start spreading it within 48 hours.

PAUL DOUGLAS: (As Capt. Tom Warren) Forty-eight hours?

WIDMARK: (As Lt. Cmdr. Clinton Clint Reed M.D.) Yes, we have 48 hours. Shortly after that you'll have the makings of an epidemic.

(SOUNDBITE OF MUSIC)

VEDANTAM: Today on the show, we have a story where life imitates art. It's a story about disease and panic, but it's also a story about psychology. To control an epidemic takes more than medical skill. It requires an understanding of human behavior and the forces that drive people to act in certain ways. Our story starts in Monrovia, the capital of Liberia. A deadly crisis was sparking fear. News reports were filled with dramatic language and catastrophic warnings.

(SOUNDBITE OF NEWS MONTAGE)

UNIDENTIFIED JOURNALIST #1: The Ebola virus is back, an Ebola break out in West Africa is, quote, "totally out of control."

UNIDENTIFIED JOURNALIST #2: A catastrophe is unfolding - the world's deadliest outbreak of Ebola.

UNIDENTIFIED JOURNALIST #3: Highly infectious, quick to kill, with no vaccine and no cure.

VEDANTAM: The Ebola outbreak reached its peak in the fall of 2014. By the end of the year, it was subsiding. But then in early 2015, in a poor part of Monrovia, there was a new outbreak or cluster. And it led to the complex case we're focusing on today.

ATHALIA CHRISTIE: I got a call from someone who said, if your passport isn't in my office in the next two hours, you won't make your flight to Liberia.

VEDANTAM: Athalia Christie is an epidemiologist with the Centers for Disease Control and Prevention, or CDC. She flew to Monrovia to help track and stop the outbreak. Lots of CDC officials joined her, like Frank Mahoney.

FRANK MAHONEY: People were scared. It was a crisis. You could drive through the city and see people that were being left out on the street, you know, for people to come pick them up.

(SOUNDBITE OF MUSIC)

VEDANTAM: Frank and Athalia told me how the case we're following today started. Police in Monrovia discovered a body in a warehouse, a young man dead with multiple stab wounds.

VEDANTAM: Police were called in. A swab was taken as mandated by the official policy that any dead body be swabbed. So even the police who arrived there initially thought they were investigating a murder, they did follow the procedures and have the bodies swabbed, at which point we were alerted because the test came back positive.

VEDANTAM: Positive for Ebola. Once police identified the youth, they quickly realized they had a major problem on their hands. It turned out the young man was actually part of a large street gang.

MAHONEY: Yeah, it was like a gang. One of them, for whatever reason, he got stabbed by other members of the group.

CHRISTIE: As we understand it, there was a knife fight and we're not quite sure how it happened but the friend turned on him.

VEDANTAM: Just to review, a young man contracts Ebola. He gets in a fight and is stabbed repeatedly by fellow members of his gang. Ebola, remember, is highly contagious. Come into contact with an infected person's sweat or blood and you could fall sick, too. The gang had as many as 35 members, each had connections far and wide across the city.

(SOUNDBITE OF MUSIC)

VEDANTAM: And just like in that movie, "Panic In The Streets," public health officials needed to quickly stop the outbreak from spreading. They needed to try and find every person who could have come into contact with the young man. It's a process called contact tracing.

CHRISTIE: It's exceedingly difficult to do. If you try to imagine constructing the last three weeks of your life and determining every single person that you came into contact with, whether it was casual contact or a family member who you saw every day, it's extraordinarily difficult to do.

So we interview people multiple times. And we also talk to their family members and their friends to try to determine everyone who might have had any contact with this person during the time that they could have been infectious.

VEDANTAM: Athalia and Frank knew the young man who died had sought medical treatment for his stab wounds. Had a health care worker sutured the young man's wounds and come into contact with his blood? Athalia visited a lot of clinics, trying to track down facilities the young man may have visited. She paged through logbooks of patient names with no luck. Then she got to one clinic.

CHRISTIE: And I took this big, dusty log book and I opened it up and literally the page I opened it to, there's maybe 30 names to a page. And I read down them and there he was at the bottom of the first page.

VEDANTAM: A health care worker at this clinic had sutured the young man's knife wounds. Athalia knew what she had to do.

CHRISTIE: The most difficult part of these investigations come when you need to tell the clinicians and all of the staff who work in these health care facilities that someone with Ebola entered the facility. And I remember how nervous the individual was when I told him that the person he sutured had been positive for Ebola at the time. It's hard to imagine what he was going through.

VEDANTAM: Can you recall what you told him and what he said?

CHRISTIE: We were standing in the hallway. And I told him that there's no easy way to tell anybody this. And so we just told him very matter of factly and that we needed to maintain daily contact and monitoring with him coming in for treatment the moment that you have symptoms. And the reason I remember this so clearly is that he didn't do that. He was very reluctant to go to an Ebola treatment unit.

VEDANTAM: The health care worker refused to be quarantined. He insisted he'd followed all safety procedures as he bandaged the young man's wounds. He told Athalia he'd get in touch if he started to have any symptoms.

(SOUNDBITE OF MUSIC)

VEDANTAM: Athalia knew there was a reason the health care worker had refused to come into an Ebola treatment unit. It had to do with a lack of trust in the system. In fact, the more Athalia and Frank saw, the more they realized that Ebola wasn't the only enemy they were fighting in Monrovia. They were dealing with an epidemic of mistrust.

(SOUNDBITE OF MUSIC)

VEDANTAM: After a long history of civil war and corruption, a lot of people in Liberia simply didn't trust the government or international organizations. When Ebola broke out, the government's first response was to try and control it using coercion, cordoning off sections of towns. It created panic.

MAHONEY: The government had attempted involuntary quarantine and they had a really bad experience in the slums of Monrovia. And so we talked about, you know, is this a viable strategy? And we all agreed, no, we can't use involuntary quarantine. This is not something that's going to build trust in the community. It's not a way to manage the outbreak.

VEDANTAM: People also worried that if they did go into quarantine, they would never come out. Athalia pointed at the construction of one of the largest Ebola treatment units in Liberia.

CHRISTIE: And it was chaotic and difficult. And they built it all and they forgot to put an exit in. They didn't build an exit because we weren't thinking about survivors at that time. And although this was many months later, many people, understandably so, thought that going to an Ebola treatment unit meant that you would not come home.

VEDANTAM: Dealing with mistrust, the public health officials knew, was central as they began to trace all the leads of this complex case. As Athalia had been tracking down the health care worker, Frank had been pursuing a different strand of the investigation - tracking down the members of the young man's gang.

MAHONEY: This was a community that was not on the best terms with the government, you know, they were very suspicious of the government.

CHRISTIE: So it really is a trust-building exercise to go into this community to piece together all these pieces of the story.

VEDANTAM: Very quickly Frank and Ophelia realized they were in over their heads. They needed help.

MAHONEY: So when we did the investigation, I went with this Liberian...

CHRISTIE: Fantastic Liberian epidemiologist...

MAHONEY: ...Person named Mosoka Fallah.

CHRISTIE: ...Mosoka Fallah.

MOSOKA FALLAH: I am Mosoka P. Fallah.

VEDANTAM: As a Liberian, Mosoka Fallah understood things far better than the Americans. He also understood the horrors of Ebola firsthand. The disease had killed his sister. Mosoka's first order of business was to help track down the young men in the gang. Surprisingly, they weren't hard to find, but they were scared. Scared that the police, who were still investigating the case as a homicide, would arrest them for their role in the knife fight.

FALLAH: The police wanted to go in. However, if we allowed the police to go in, the gangsters would all escape and we'll have pretty close to 35 young men who are all high-risk contact on the loose.

VEDANTAM: This is similar to what happened in "Panic In The Streets."

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

MAHONEY: (As Capt. Tom Warren) Wait a minute, Neff. Wait a minute.

DAN RISS: (As Neff) Wait for what, somebody else to die?

FALLAH: Frank suggested that there should be no arrests.

VEDANTAM: Mosoka says Frank sat down with the police. He told them that any investigation of the murder would send gang members into hiding and potentially spread Ebola further.

VEDANTAM: If you allow the Ebola team to go in and negotiate so that we can have the contact. And the police agreed. And the police withdrew the arrest. And that's how we went in to negotiate.

VEDANTAM: And this, everyone told us, is what allowed public health officials to start talking to the young men in the gang. So to recap, public health officials had tracked down the health care worker who treated the young man and identified all the people they could tell the young man had come into contact with. The epidemiologists quickly found themselves staring at a growing web. There were three important strands.

First, the young men in the gang would have to be persuaded to enter an Ebola quarantine facility for 21 days. Second, there was a woman running a drug house who was connected to the gang. Gang members were in and out of her home all the time. Most worrisome, the public health officials heard the woman was sick and they thought that she might have Ebola.

FALLAH: She had had diarrhea for two days and she was getting sick.

VEDANTAM: Finally, there was one member of the gang they could not track down. During the fight, this man had held down the stabbing victim as the blades came out and the blood splattered. And now, Frank and others found, he'd run away.

What was his name?

MAHONEY: His name, ironically, was Time Bomb.

(SOUNDBITE OF MUSIC)

VEDANTAM: Coming up, how to stop the outbreak and find Time Bomb. Stay with us.

(SOUNDBITE OF MUSIC)

VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. We're exploring how in early 2015, epidemiologists tried to stop Ebola from spreading in a poor slum in Liberia. They had three fires to put out. Time Bomb had gone underground. The rest of the gang had been identified, but were reluctant to be quarantined.

And then there was the woman known as Drug Mama. She was the godmother of a drug den frequented by members of the gang. She was in her 30s and appeared to have symptoms that suggested Ebola. If Ebola struck the heart of the drug den, it would spread very quickly through the community. Frank and Mosoka realized they had to quickly run a test to get Drug Mama diagnosed, but they anticipated problems.

FALLAH: Our dilemma was, how do we approach her such that she accepts us to do an Ebola test?

VEDANTAM: The mere mention of Ebola was sending people into a panic. If they told her they were worried she had Ebola, would she vanish and go underground? They didn't want to take the chance. So rather than take her into confidence, they decided to trick Drug Mama. It wasn't ideal, but they were dealing with a crisis. They had to improvise.

FALLAH: So Frank being the smart guy he is, we stopped at a pharmacy and we bought her malaria medicine. And we went there that night and Frank said, I heard you're not so well so we brought you some medicine. This is around 9 p.m. She said, yes. So Frank said, take this medicine. I will come back tomorrow and check on you. And so the goal was the next morning I asked for her blood to go check if she had malaria and then we'd run an Ebola test.

VEDANTAM: The trick worked up to a point. The problem was the next morning when they took Drug Mama to the hospital to get her blood drawn, they had to tell health care workers at the hospital what was going on so everyone would take proper precautions. A nurse got scared when they told her they wanted to test for Ebola. Drug Mama noticed the nurse acting oddly.

FALLAH: And then she suspected something else. The Drug Mama left and went back home and became angry with us.

VEDANTAM: Mosoka and Frank realized the trickery was backfiring, so they tried bribery.

FALLAH: We sat down with her. We negotiated and we told her we'd give her $100 U.S. if she allowed us to do a blood draw at her house. So we took the blood. And at 7 p.m. that night we got a response that she was negative. And we all went to bed breathing a sigh of release.

(SOUNDBITE OF MUSIC)

VEDANTAM: Frank and Mosoka turned their focus to the second strand in the web - the young men in the gang. Patiently, they explained to the young men that they would be safe from police harassment in the Ebola treatment unit.

MAHONEY: We worked it out with them. We made a - we worked out an arrangement where they - if they agreed to come in to the isolation facility, you know, the CDC, I think we ended up paying their families some support costs 'cause they were no longer able to earn money for their families. And the government provided the families with food. And so it worked out really well.

VEDANTAM: But even this was not enough. It turned out some of the young men were drug addicts. Frank realized he had to keep asking the government to bend the rules in the Ebola treatment unit or ETU.

MAHONEY: I told the government that we had to anticipate that some of these young men may be drug users and they may go into withdrawal if we put them in the ETU. And, in fact, that was the case. About two to three days later they were - some of them getting agitated. And somehow they found a way to support their needs for drugs.

VEDANTAM: Did you have to do some of that to help them get what they needed to keep them in this facility where they could be quarantined?

MAHONEY: No. I - the CDC didn't pay for that or do that. But the government found a way for the communities to support them so they were doing that.

VEDANTAM: So - in - but in some ways it's sort of an awkward situation for the government because in some ways you're asking...

MAHONEY: Exactly.

VEDANTAM: ...The government to sort of look the other way while someone's doing something illegal here.

MAHONEY: Yeah. I think that they - but at the same they - it'd be like any withdrawal. They needed treatment. It wasn't a conventional treatment, that's for sure.

VEDANTAM: It was odd for public health officials to be sanctioning illegal drug use. But again, when you're in the middle of an unfolding catastrophe, you sometimes have to bend the rules. Even though CDC wasn't actually supplying anyone drugs, the arrangement produced lots of double takes. One day a Liberian government minister turned to Frank during a discussion and joked about the back door drug channel.

MAHONEY: And (laughter) he says, and I understand that CDC is providing them with the marijuana. And I said excuse me, sir, I said I'd like to correct that. I said CDC is not providing the marijuana, that - but we're providing the cocaine.

(SOUNDBITE OF MUSIC)

VEDANTAM: Incredibly, the epidemiologists actually managed to quarantine the gang members. These were young men who no one thought would listen to the authorities. But by reposing trust in them and treating the young men as partners, the public health officials had found a solution that seemed to work better than coercion or trickery. Still, this wasn't the end. There was a third strand of the web they had to track down - Time Bomb.

FALLAH: Time Bomb became very elusive. We could not find Time Bomb.

VEDANTAM: At first, gang members did not want to tell Mosoka or Frank where Time Bomb was.

FALLAH: But as we built friendship and rapport with the other criminals, one of them took us to his house.

VEDANTAM: There they found a young man, a young woman and a baby. The epidemiologists asked the young man if he was Time Bomb.

FALLAH: He said, I'm not Time Bomb. Time Bomb is gone out. I'm his younger brother. But if he comes back, I will let you know. Then I said, OK, thank you very much.

VEDANTAM: It was at this point that Mosoka and Frank did something very kind and very wise that led to a breakthrough in the case.

FALLAH: The wife had a young baby. And I remember giving the wife a hundred dollars and said, go ahead and buy milk for the baby. Feed the baby and we'll take care of you.

VEDANTAM: Something changed in the young man's demeanor.

FALLAH: After I did that, he turned to me and said to me, I am Time Bomb.

(SOUNDBITE OF MUSIC)

VEDANTAM: Frank and Mosoka told Time Bomb and his wife that they would be back that night. They promised they would return with more food.

FALLAH: Frank came to me with the food and said, Mosoka, we need to go to meet this guy. This was in the ghetto.

MAHONEY: I went with Mosoka and it was like 10 o'clock at night.

FALLAH: There was no electricity. This place was pitch black. We had to go and drive through the grass. This is - was like a slum community. It's known to have gangsters. And that's what Frank was emphasizing, that we had to keep our word. They had to trust us.

VEDANTAM: This was the key.

MAHONEY: So we brought food to him and his family, I think a couple sacks of rice and things.

FALLAH: As walked towards them and they saw us coming with rice on our shoulder, for some reason they trusted us and they came to the car and helped us take the rice.

VEDANTAM: Frank and Mosoka gently asked Time Bomb whether he was willing to come to the Ebola treatment facility to be quarantined. Time Bomb said he wasn't ready to do that. Frank and Mosoka said they understood, that they were willing to trust him to do the right thing.

FALLAH: If you get sick, you call us. And he said, I will do that. I trust you guys.

MAHONEY: And so I think it was a matter of building up a trust and comfort level for him to talk to us.

(SOUNDBITE OF MUSIC)

VEDANTAM: In the end, none of the young gang members contracted Ebola, not even Time Bomb. The cluster did not spread in the ghetto. Drug Mama recovered from her illness. Only one person connected with the cluster was affected. The medical worker who'd sutured up the young man's wounds, the one that went into hiding after Athalia talked to him, he came down with Ebola-related symptoms. Eventually he did seek treatment, but it was too late.

CHRISTIE: He died unfortunately in the Ebola treatment unit.

(SOUNDBITE OF MUSIC)

VEDANTAM: We started today's episode with the 1950 movie "Panic In The Streets." At the end of that movie, the hero - a public health worker - ends up in a warehouse with the criminals who are carrying the deadly plague.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

WIDMARK: (As Lt. Cmdr. Clinton Clint Reed M.D.) I'm a doctor and I can cure you.

VEDANTAM: He pleads for them to hand over their guns.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS")

WIDMARK: (As Lt. Cmdr. Clinton Clint Reed M.D.) Come out now and surrender and I promise nothing will happen to you.

VEDANTAM: But...

(SOUNDBITE OF FILM, "PANIC IN THE STREETS," GUNSHOTS HEARD)

VEDANTAM: ...They get into a climactic shootout and the criminals are killed.

(SOUNDBITE OF FILM, "PANIC IN THE STREETS," GUNSHOTS HEARD)

VEDANTAM: The public health workers in Liberia never solved things with guns. And really, when it came down to it, Athalia says, they achieved some of their best results without coercion or trickery. Building those invisible but very real bonds of trust took time, but it was essential to stopping an outbreak.

CHRISTIE: When it comes down to what we were asking people to do, either to trust the health care system or to trust the government enough to agree to this voluntary precautionary isolation, that's an extraordinarily difficult thing to do. You're asking people to leave their friends and family for 21 days. Or we were asking people to change their burial customs. And it's difficult. It can sound simple.

And I know that I spoke to people here who would say, I don't understand, why can't they just change the way they bury the dead or change the way they care for their family members if they're sick? But as a mother, I can't imagine not touching my child if he was sick and not trying to provide comfort.

So it's really understanding what it is that's that's driving people. You have to understand their contexts, their concerns and their needs. I think it's about interpersonal relationships. You have to be honest and straightforward about what you need and why. And most importantly, I think you need to be human.

(SOUNDBITE OF MUSIC)

VEDANTAM: This episode of HIDDEN BRAIN was produced by Chris Benderev and edited by Tara Boyle and Jenny Schmidt. Our staff includes Maggie Penman and Renee Klahr. We had original music from Ramtin Arablouei. To find more HIDDEN BRAIN, go to Facebook and Twitter and listen for my stories on your local public radio station.

Our unsung hero this week doesn't work at NPR. He's Tom Frieden, director of the Centers for Disease Control and Prevention. He got in touch some time ago to say he loved the show, but wanted to know why we weren't doing more stories about public health. I told him those stories tended to be a little dry. He said, wait a minute, I've got a great one for you. Tom, you were right, this was a great story.

If you have an idea for a HIDDEN BRAIN, episode a topic with interesting ideas and great characters, drop us a line at hiddenbrain.npr.org. I'm Shankar Vedantam and this is NPR.

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