American virologist Joseph Fair has been living in Sierra Leone for much of the last decade, most recently advising the ministry of health on how to cope with the Ebola outbreak. Last month, when he visited the community hospital in Kenema, 186 miles (300 km) inland from the capital city of Freetown, he greeted old friends with warm embraces. Within two weeks, three of them were dead, felled by Ebola, which the World Health Organization Friday declared a Public Health Emergency of International Concern, its highest level of alert.
With his grief still raw, Fair, a special advisor to the ministry of health, works 12-plus-hour days helping to coordinate the country's response to the largest Ebola outbreak in history. Fair spoke with National Geographic between conference calls aimed at Ebola response.
How are people there responding to the outbreak?
There was a lot of denial very early on in this epidemic. I feel like we've turned the corner. You see much less denial that the disease exists.
Going into a restaurant, you are forced to wash your hands with chlorine and water before you go in. That's standard at most places in town. Those in the affected zone have learned not to shake hands or hug. There's a striking difference between now and a normal day, if someone has a fever.
How are health care workers in the region coping? Dozens have died across the region since the outbreak began.
There's been a lot of abandoning ship, for lack of a better way of saying it.
It's hard to blame them for leaving.
Indeed. You are facing something very dangerous. This is just like a war. You have people who either run toward danger or run away from it. Both are understandable. And there's no shame in either.
Is anyone coming to take their place?
You have young graduates dying to get into the fight and they're not even being paid yet. The hope and the future of this area is we have young, brave nurses, doctors, and community health workers.
What is the infrastructure like in Sierra Leone? Can it handle the outbreak?
In a city of over 200,000 people, there's no power grid. Imagine a city being run off of a generator and trying to operate any kind of high-tech equipment, like a ventilator. It's just not possible.
What can be done to bring Ebola under control?
The only thing that is going to change the course of this epidemic is actual epidemiology. We need to stop the disease from being transmitted. You're a positive case: Who did you have contact with? Who did those people have contact with? Do we have a motorcycle or truck we can send out to interview that person? Will the person be willing to be interviewed? Or have they already run off to seek treatment or to another city?
You're dealing with an extremely poor country. Just having the vehicles available to go do that, be they motorcycles or trucks, etc., [isn't a given].
Aren't you worried about your own safety being in Sierra Leone?
For me, sitting next to a minister in a World Health Organization office, I am not in that great of danger. I had close contact with a close friend who did pass a few weeks ago, but I consider that [contact] minimal. There are people who are on the front lines.
What do you think motivates people to put themselves in harm's way like that?
What motivates anyone who goes into this type of work? The first people who volunteered were veterans in Kenema who were used to treating Lassa fever [a virus similar to Ebola].
Your friends who died and the Americans who got Ebola were all trained and experienced in caring for patients and they still got sick. Is this Ebola strain more dangerous, or were they just too exhausted to follow proper protocol?
The second. Your patient load during an outbreak of this magnitude doubles, quadruples. Then you have the new people.
Are the newcomers not trained well enough?
Professionals go through years of training in how to be careful, what small mistakes not to make. Imagine rolling into a setting, taking on volunteers to help you fight the fight, giving them as much training as you can.
Combine that with working 12 to 14 hour shifts. You're now wearing full personal protective equipment in an environment where the average temp can [top 95ºF]. You're sweating. You probably haven't eaten, because there's been no chance to take a break to eat. Maybe you had a few weeks of training. Let's say you have an itch on your nose and instinctively you reach to scratch that itch—you've just exposed yourself.
Is the ministry of health looking for more volunteers?
We're looking for volunteers. Medical students, for instance, who can help us work at the airport to screen [to make sure people don't carry the virus to other countries]. As many qualified people who are willing to volunteer, we are willing to take them and twin them with people who do have experience. And get them into the fight.
After one friend's funeral, you went to a bar to take the edge off your sorrows. There, you met a teenage boy who impressed you.
He said, "I want to help my country, how can I volunteer?" While dealing with a devastating personal loss, I couldn't help but smile that there are still people like that young man. Those are the people we're counting on.
One friend you lost to Ebola was Sheik Umar Khan, who has been called a "national hero" for his work against Ebola.
We've been friends for ten years. He was a bright and shining personality who was always laughing and had a contagious smile. He had just finished his infectious disease fellowship—something of which he was enormously proud. Ten years ago, when his predecessor died in the same fashion—of a direct needle stick from a Lassa patient—Dr. Khan was the only volunteer who would be the new Lassa doctor. He was really a very brave young man.
You also lost your friend Mbalu Sankoh, a nurse matron at the same Kenema hospital, who also died from the virus?
She had been a nurse for 25 years. She herself had survived Lassa. She was a mother to all of us who came and worked there. She was the one who held [everyone] together.
How does the hospital go on at a time like that?
Both of their leaders died within a few weeks of one another, which has been absolutely devastating. Right now we're incredibly stretched. We all work for different organizations, but we all had a common bond.
This outbreak is occurring in a region that recently endured years of civil war. How is that affecting people's willingness to cooperate with government officials who are trying to rein in this outbreak?
You're dealing with nations [Sierra Leone and neighboring Liberia] that dealt with almost a decade of civil conflict. There was a very gray line of who was causing the problems. Both of them were on the road to recovery. The civil war is very fresh in their minds.
Is the rest of the world doing enough to help these countries?
The U.S. is obviously contributing, along with the international community. We have work to do on better coordinating our efforts—how we invest, how we deal with these diseases. Certain investments the U.S. has made since 2001 have obviously made us better prepared to respond; others have not been as effective in this response.
You are still mourning your friends. How are you managing to work?
Obviously, it makes one very emotional and harder to be objective. There has been no time to breathe. It's not just me, it's everyone who's lost family members or continues to lose family members. We're still in the middle of the epidemic. It's been incredibly difficult to bear.
This interview has been edited and condensed.