Paul Molinaro is not looking forward to Christmas. He’s no Scrooge. But when you’re trying to keep an Ebola outbreak response up and running, the season of celebration and good cheer is a major inconvenience.

Rather than anticipating family gatherings, festive feasts, and brightly wrapped gifts, Molinaro, chief of operation support logistics for the World Health Organization’s emergencies program, dreads the likelihood of shops being closed, customs operations being understaffed, and pretty much everything he and his staff need to get done being that much more taxing over the Yuletide.

“Suppliers will tend to start shutting down for the holiday season. It becomes harder to get the windows of delivery because you may anticipate Kinshasa airport being a lot slower. It just becomes a pain for me,” said Molinaro, who is overseeing a team of several dozen logistical workers on the ground in the Democratic Republic of the Congo, and at WHO headquarters in Geneva.

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When we think of Ebola outbreak responses, chances are what comes to mind are courageous doctors and nurses caring for people afflicted by one of the cruelest and most deadly diseases known to man. What we tend to overlook is the mountain of work needed to ensure there is a treatment unit in which to care for the sick, and that there are boots and gloves and aprons and face shields to protect the medical staff.

Outbreak logisticians are the people who supply the response teams, who find them beds to fall into at the end of exhausting days, and food to sustain them and vehicles to transport them. It’s their job to create the conditions in which the people who know how to stop Ebola can get that essential task done.

When the right equipment is in the right place and in the right amounts, it “seems like magic,” Molinaro said. But in reality, it’s a lot of hard work.

Molinaro’s crew is supporting the upward of 300 people working for the WHO in northeastern Congo to extinguish this latest Ebola outbreak, which is now the second largest in history. As of Wednesday there have been 549 cases and 326 deaths since the outbreak began, likely in late April.

In addition to the WHO, there are several dozen international agencies and non-governmental organizations assisting the Congolese government in the battle to end this outbreak. They all need accommodations, meals, medical equipment, power generators, structures in which to care for the sick, vehicles in which to move from town to town, satellite phones or cellphone SIM cards, and more — much more.

The effort involved in sourcing all these necessities of work and life so that the Ebola responders can work on issues of life and death are divvied up among different partners in the response, Molinaro told STAT.

“Some of the partners, they have their own setup. It’s better like that; they know what they want in terms of their setup, the way they do their clinical management or care,” he said, noting this is especially true for the main medical NGOs that operate the Ebola treatment centers, ALIMA and Doctors Without Borders, which is known by the acronym for the French version of the name, MSF. “It’s definitely a team effort.”

Kim Comer, emergency logistics coordinator for MSF, was in DRC this week overseeing construction of a new treatment center in Katwa, a neighborhood in the large city of Butembo. Transmission of Ebola is picking up there, and a new treatment center is needed. The work involves everything from bulldozing the field to erecting fencing and hospital structures of wood and plastic sheeting, putting in latrines, installing generators to provide electricity, and myriad other things.

“If I could just work 20 more hours today, I could get my to-do list done,” said Comer, who is on her third Ebola outbreak. “But there’s just no way to get the list done.”

Case in point: The 27 staff bedrooms at the Katwa camp are already full, so more beds were being brought in, and people will have to double up.

ALIMA, which is operating a 61-bed Ebola treatment center in Beni, where the outbreak response is headquartered, goes through about 100 sets of personal protective equipment — PPE in infection control parlance — daily, ordered from Europe or North America, André Jincq, the organization’s emergency response logistics coordinator, said in an email. Ensuring that the critical supplies are always available requires careful advanced planning. Without this protective gear, treatment centers could not safely function.

Comer said MSF tracks the global stocks of coveralls to ensure the supplier is able to produce what aid workers need. The group has already stockpiled PPE supplies in Goma, a large city south the outbreak zone. There haven’t yet been cases in Goma, but there is concern the virus will make its way there, and the logisticians don’t want to be caught flatfooted.

“Your teams are telling you: XY is probably going to happen. We should increase A, B, C, and D to anticipate. We then go ahead and do that,” Molinaro explained. “And then when A, B, C, and D is needed, it seems like magic to the users that these things are just there. But these things arrived there after a process of discussion, really assessing the risk and then taking a call on whether we should forward something or not.”

This is Molinaro’s first Ebola outbreak. He joined WHO in mid-July and quickly “got thrown into it,” he said. (The outbreak was declared Aug. 1.) Prior to joining the WHO, he worked for the United Nations International Children’s Emergency Fund — UNICEF — in the Middle East. So he’s done this type of work before. But little else has the urgency of an Ebola outbreak, he said.

“Here we’re dealing with a situation if we’re not able to get a vaccination team in, equipped, and around the case and the contacts within a very short period of time — measured in hours — there’s potentially the chance … the virus moves on, infects, and kills people,” he said.

These days, most of the spread of Ebola is occurring in the cities of northeastern Congo, which is both a curse and a blessing. A curse because urban outbreaks are harder to extinguish. A blessing because it’s easier to meet some of the logistical needs than it would be in rural, difficult-to-access areas, suggested Yves Willemot, head of communications for UNICEF’s DRC country office.

Staff can be housed and fed in the hotels and restaurants of Beni, Butembo, and Goma, said Willemot — though he did acknowledge there is fierce competition for hotel beds.

“If you have 300 people from WHO and 50 from UNICEF, there’s a constant rotation of people coming in and people going out and rooms becoming available and new rooms being requested, etc. It’s a constant ‘fight’ to get rooms,” he said, supplying the air quotes. “And so the circumstances in which people are working and living are not necessarily always very easy.”

All those people need to get around. That means hiring vehicles, which can require some creativity, noted Molinaro, who said the WHO has a fleet of about 350 vehicles at its disposal now.

“Right at the beginning … it’s seeing a car come by and then asking, ‘Would you like to hire this [out]?’ And then word getting out and vehicle owners starting to present themselves and then you start going into a bit more of a process,” he said. “Inspecting the vehicle. Testing the driver. Coming up with a standard contract.”

The outbreak response has also been able to draw on the resources of a United Nations peacekeeping force, MONUSCO, which has been operating in the region for nearly two decades. About 40 of the vehicles at WHO’s disposal are MONUSCO vehicles on loan. They come equipped with radio communications — a “stroke of luck,” said Molinaro, given that it’s safer if a convoy of cars includes one with a radio.

The safety of outbreak response workers is an enormous concern in the region, where rebel forces have been known to kidnap and kill. On Monday, a World Food Program worker was killed in an ambush north of Goma.

Molinaro said the response teams are using a smartphone app developed by the International Organization for Migration that allows them to keep tabs on staff in the field. “It has a panic button. It has an ‘I’m OK’ button. ”

Because of the security concerns, there are actually two types of personnel protective equipment needed by outbreak staff. Molinaro calls them PPE-H (for health) and PPE-S (for security). The latter refers to Kevlar vests and helmets — not exactly standard attire in an Ebola outbreak.

One service that had been on Molinaro’s to-do list turned out to be too difficult to execute, even for a crew of people who get the impossible done. He’s not 100 percent sure how people working for the WHO are getting clean clothes.

“It’s something that we were trying to put into place. But it’s actually a lot of work. Because you have to identify whose laundry it is. You have to make sure when it’s done it’s all going back to that owner,” he said. “That in itself would be a logistics operation of remarkable precision…. Laundry really goes into micro-planning of ‘I don’t have two socks.'”

He’s curious about how the laundry dilemma has sorted itself out, but he suspects staff have found a local fix. “I think it ended up just kind of evolving through capitalism,” he said.

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