The Best American Magazine Writing 2016

by Sid Holt

  Khan advised the hospital nurses and doctors to brace themselves: About 80 people had attended the herbalist’s funeral—a ritualistic practice that involved washing and dressing the corpse and crowding around to lay their hands on and kiss the body. At least fourteen funeral-goers were now sick. “He said to me and [fellow nurse] Alex Moigboi, ‘You should tighten your belts, we are expecting two ambulances from Kailahun,’” recalls nurse John Tamba. Two days later, Garry of Tulane University came to Kenema, bearing nine trunks filled with gloves, gowns, and every possible brand of PPE that he could find. Nine hundred “changes” in all. But in the first weeks, the disease was little understood by the staff. Many nurses disregarded safety protocols and worked the ward wearing surgical gowns and old shoes that they had brought from home. People removed their vomit- and diarrhea-covered equipment without hosing it off, then washed their hands with a perfunctory splash of chlorine. “A lot of people at the hospital got sick right away,” says nurse Issa French. “We learned that it was a different disease than anything we’d ever seen before.”

  Khan traveled to the epicenter of the outbreak in Kailahun to try to convey to village people the dangers of the disease. He took blood samples, held workshops for local health-care workers, and helped to evacuate the sick. Villagers, he found, were in denial, blaming the illness on the dead herbalist’s snakes. They resisted going to the hospital. Local officials, fearing the spread of panic and unrest, weren’t helping. On one occasion, a local chief spitefully seized Khan’s government-issued four-wheel-drive Toyota and held it overnight, warning him to stay out of Kailahun. In Koindu, the home of the healer, the population put up roadblocks and threw stones, breaking the windshield of the four-wheel-drive vehicle. “There were rumors that we were coming to give them the disease. They said we would take people away and never come back,” says Garry, who traveled to Koindu chiefdom in late May. “The attitude was, ‘Leave us alone.’”

  Even those close to Khan had a hard time understanding the infectious power of the virus. During one trip north, Khan was about to step into his Toyota Land Cruiser when he noticed a sick woman lying sprawled in the back.

  “Who is this?” he asked his driver.

  “This is my sister, Dr. Khan.”

  “Who put her in the car?”

  “I did,” his driver replied.

  “You? My God. Just stay outside the car.”

  Days later, the driver died of Ebola. Khan never used the Land Cruiser again.

  • • •

  By early July, more than a month after Khan first recognized the virus, the outbreak had moved from Kailahun to Kenema district. Across the region, the disease was spreading uncontrolled, carried by truckers and farmers and motorcyclists on a network of roads that ran from bush to town to city. The World Health Organization responded to the crisis by delegating authority to its regional offices, which in turn deferred to the governments of West Africa. But officials in Freetown were in denial about the severity of the outbreak. They didn’t declare a state of emergency until August. And even then, they faced an acute shortage of hospital beds, ambulances, burial teams, and investigators. Ambulance drivers often crammed sick people and uninfected relatives into same vehicle. When hospitals were full the sick were placed on home quarantines, and when food wasn’t provided the sick would go to markets and spread the contagion. “We had no strategy, no laboratories, no observation centers. We were completely unprepared,” said Victor Willoughby, a veteran Sierra Leone internist with whom Khan did his residency in the early 2000s. The wards at Kenema were overflowing.

  “The situation was chaotic,” recalls Will Pooley, a British nurse from King’s College Hospital in London who arrived to work on the Ebola wards in early July. When he first met Khan, the doctor was huddled with a visiting CDC scientist in his office, a small, cluttered trailer beside the isolation wards, trying to work out how many members of the nursing staff had died—between ten and fifteen, at that point. Khan shook Pooley’s hand warmly, trying to make him feel welcome. Khan, Pooley says, was “the general,” poised, in command, and working hard to hold things together.

  Each morning from that point on, Pooley donned his protective suit and crossed a barrier of orange plastic mesh into the red zone. He started his rounds in the “Annex,” a large white canvas tent filled with those awaiting their diagnostic results; some were already near death by the time they arrived at the hospital. Pooley frequently found corpses sprawled in the toilets, lying in pools of contaminated blood from the IV lines that they had ripped out of their arms during the night. One morning he walked into the ward and saw a naked male adult lying dead on the floor, and a “sweet-looking” naked toddler sitting in his blood. Somehow, the toddler survived.

  Confirmed Ebola cases were remanded to Ward A, the former Lassa fever unit. One CDC official recalls following Khan inside, stepping over corpses in body bags lying on the walkway before the entrance. Within five minutes of entering the ward, he says, the oppressive heat and humidity in the windowless unit caused his plastic visor to steam up. He groped his way forward, banging into cots, too frightened to adjust the eyewear and risk exposing his skin to viral particles. Khan, he noticed with alarm, lifted his goggles from his face several times to defog them.

  Just outside the entrance of Ward A stood a small shed where corpses were stacked like cordwood; the bodies often spilled over and lay scattered on the walkway. One day, trying to identify patients who had died overnight, Pooley unzipped a body bag and came face to face with a corpse wearing a protective suit—”masks, goggles, the full gear,” he says. “I was wearing my suit, this guy was looking back at me, and it was as if I was looking into a mirror.” (Ambulance attendants sometimes put infected Ebola patients into PPEs before transporting them to the hospital in a misguided attempt to protect themselves; the patients often died of heat stroke.)

  After a few days working in the red zone, sometimes alongside Khan, Pooley calculated his chance of catching Ebola at 50 percent. If he got it, he figured that he stood a one-in-two chance of surviving. “I was thinking, ‘How can I exit this situation without being a complete disgrace?’” he remembers. “Weeks went by, and then it wasn’t possible to leave…I didn’t want to look like a coward.”

  • • •

  By July, Ebola was raging across three West African countries—Guinea, Sierra Leone, and Liberia, infecting more than eight hundred people and killing more than half of them. From Kenema, the virus made its way toward Freetown. On June 20, Doctors Without Borders declared the outbreak “totally out of control,” and one week later the organization opened an Ebola treatment center at the epicenter in Kailahun—the first international medical organization to open a facility there. On July 17, the number of cases in Sierra Leone reached 442, surpassing the total in Liberia and Guinea. More than half of those had died. Every week, as many as seventy suspected Ebola patients were pouring into Kenema Goverment Hospital. Khan was working fourteen-hour days, too preoccupied now to unwind in the evenings at The Capitol, where crowds gathered to watch the World Cup in Brazil.

  “I don’t have any time for the World Cup anymore, Alaska,” he told his nephew. “I’m either in the ward or the lab.”

  “Why can’t you just leave Kenema?”

  Khan laughed ruefully. “At a time when the whole country is looking to me, is it the time to run away here?” Khan replied. “Do you know what you were telling me to do? Abandon my profession.” He optimistically told his nephew that he had just discharged forty-five people that day.

  “I want to come to Kenema, to see you,” Alaska told him.

  “No. You have to stay away from here.”

  “I’m really worried about you.”

  “Don’t worry about me,” Khan said. “I am well protected.” To reassure him, he sent a photograph taken in the Ebola ward showing Khan and two colleagues covered head to foot in their PPEs. Scrawled on the apron of the man standing to Khan’s left was the name “Alex Moigboi.” The nurse, K
han’s closest friend at the hospital, would die a few days later of Ebola.

  Khan was known to be meticulous about safeguards: He had even installed a mirror in his office in a small trailer beside the red zone, to check for tiny holes in his protective suit before entering the isolation ward. By now the staff had become well acquainted with their enemy. He and his colleagues knew that one tiny slip-up, one tear in the PPE, could have lethal consequences.

  But Khan was overwhelmed with work, fatigued, and stressed. “He was animated, he was go-go-go, but he was also distraught. He was worried about the survival of the whole program,” recalls a CDC scientist who spent several days with Khan and his staff in mid-July.

  Nurse John Tamba believes he can pinpoint the precise moment when Khan dropped his guard. It was about five p.m. at the end of a long mid-July day. Khan and Alex Moigboi left Ward A and walked together, in their protective suits, to the decontamination area. Staff members sprayed each man down with a 30 percent chlorine spray. Their PPEs were bagged and removed for disposal.

  As they stood together in their civvies in the low-risk zone, Moigboi confided to the doctor that he was not feeling well. Khan immediately began an examination. He reached for Moigboi’s eyes, looking at his pupils. “He touched his skin,” recalls Tamba. Perhaps, Tamba speculates, it was a momentary lapse of attention, or maybe he was in denial, unable to accept the possibility that his favorite nurse had contracted the disease. Whatever the case, Khan assured Moigboi that he was suffering from malaria, and advised him to have his blood tested. “We will prove that it’s nothing to worry about,” Khan said.

  The following day, Moigboi’s blood results came back positive for Ebola, and he was taken by ambulance to Kenema Government Hospital. Khan was devastated; he was also concerned for himself. “He remembered that he had touched Alex’s bare skin,” says nurse Issa French. It’s not clear that the contact with Moigboi was responsible for what happened next—Khan had possibly exposed himself to Ebola infection several times inside Ward A when he removed his goggles—but at least three Ebola unit nurses witnessed the moment, and they all cited it when trying to explain the events that followed.

  On July 19, Alex Moigboi died in Ward B, delirious and incoherent in his final hours. That evening, Khan returned home despondent—and more tired than usual. He had the chills, and he was running a slight fever. He told his assistant, Peter Kaima, that he was worried. “Doc,” said Kaima, “you’re under a lot of stress. Your staff is dead. Maybe you’re traumatized. Don’t think about something that is not inside you. Try to calm yourself down.” The next morning the fever had abated, and Khan returned to the hospital for a day on the ward. That evening he addressed an audience at the Kenema community center. Sunday brought a setback: he awoke with a fever, too sick to work.

  “Don’t come closer by me, don’t touch me,” he warned Kaima that evening.

  Khan went to the hospital on Monday for a blood test. The result came back a few hours later: negative. That day, Mbalu Fonnie, his beloved head nurse, died. “He called me in a dull voice, and he said, ‘Alaska, Nurse Fonnie is dead. She was like my mom,’” recalls Khan’s nephew. The next day, with Khan still ill, the laboratory ran the diagnostic test again. At two that afternoon the district medical officer and other officials arrived at Khan’s home.

  “You should go outside,” they told Kaima.

  Hovering in the doorway, Kaima watched a slumped-over Khan receive the news: the Ebola test had come back positive.

  • • •

  Medical officials were immediately concerned about how Kenema’s patients and staff would receive the results. “If people know you are sick,” the chief medical officer told Khan, “everyone will panic, they will leave Kenema.” The officer made it clear that the best choice would be for Khan to go to the Doctors Without Borders center seventy-five miles to the north in Kailahun. Khan acquiesced.

  After a five-hour ambulance ride, in heavy rains and over a rutted dirt and mud track, Khan was received by physicians in protective gear. “I can walk inside myself,” he told them. They led him across a barrier of orange plastic mesh and into the isolation zone: six white tents, each one containing eight “cholera cots,” military-style beds with holes cut out for defecation. The doctors immediately placed Khan on a standard regimen of oral treatments—paracetamol for pain relief, antibiotics for diarrhea, and rehydration salts. Doctors Without Borders seldom use intravenous fluids with Ebola, believing that the risks of death from bleeding are greater than the potential benefits.

  Almost as soon as Khan entered isolation, a debate began about how to save him—one that would be steeped in agonized second-guessing and lingering controversy. On July 22, Sierra Leone’s government sent an e-mail to medical experts around the world seeking information about a drug or a vaccine that might help. The appeal prompted a round of conference calls involving the World Health Organization, the U.S. Centers for Disease Control and Prevention, the Public Health Agency of Canada, the U.S. Army, and Doctors Without Borders. The discussion focused on ZMapp—an experimental vaccine manufactured from mouse-human antibodies grown in tobacco plants. The vaccine, which had cured 100 percent of eighteen rhesus monkeys that had been given Ebola in a lab, had never been tested on a human. But three vials of it were being stored in a battery-powered freezer in the isolation ward just steps from Khan. They had been left there in June by a researcher at the Public Health agency of Canada’s research facility in Winnipeg as a way to test the vaccine’s durability in tropical environments.

  The drugs were a gift. “Everyone was on board for giving it to him, and I got off the phone thinking, ‘He’s got it,’” says one medical officer who participated in a conference call. There was some trepidation about giving Khan a drug that had never been tested on humans, but almost everybody, it seemed, believed that the potential benefits outweighed the risks. “Everybody agreed that it made sense that a very informed and important person, who had treated more patients with hemorrhagic fever than anyone else in the world, should be given the experimental drug,” says the medical officer. But the final decision was left to Khan’s primary caretakers: Doctors Without Borders and the World Health Organization.

  “At the end they got cold feet,” says the medical officer. “The thinking was, ‘He’s such a high profile individual. If we do it and we screw up we’ll be in big trouble.’ I think they should have gone forward. Khan would have wanted it. The family would have wanted it. But they panicked. It was a very hard decision that nobody wants to make, and you have to respect them for it, whether it is your choice or not your choice.”

  On July 25, the international groups finally informed Khan that they had decided against treating him with ZMapp. (Khan was made aware of the debate but was never asked for his opinion.)

  Yet there was another potential way to save Khan’s life. While the ZMapp debate intensified, Sierra Leone’s government contacted an air-ambulance service to arrange for an evacuation to a better-equipped hospital in Western Europe or the United States. A jet reportedly owned by International SOS, founded by two French doctors in the 1980s, landed at Lungi Airport outside Freetown. Equipped with a single-person isolation unit, the jet sat on the runway while the minister of health, Miatta Kargbo, frantically contacted counterparts in Germany, Switzerland, and the United States, trying to arrange Khan’s transfer. (International SOS would not comment on whether its plane was involved in the attempted rescue operation.) According to C. Ray Khan, who was in daily communication with Kargbo, Western governments all rejected the minister’s pleas—none were apparently prepared to deal with the backlash from allowing an Ebola-infected patient into the country—but finally one country, possibly Germany, agreed to take him in.

  No one had ever before attempted to air evacuate an Ebola patient. Doctors pondered whether they could treat Khan, who was vomiting and had diarrhea, in a small space without becoming infected themselves, and whether Khan could withstand the stress of being shuttled by ambulance t
o Lungi Airport and then put on a plane.

  Conditions had to be perfect. Several times a day, the Doctors Without Borders physicians measured Khan’s white blood cell count, relaying the numbers to Kargbo. The count dropped sharply and then rose but, according to the version of events that Khan’s brother received in daily conversations with the minister of health, always remained too low to move him.

  Khan’s symptoms fluctuated accordingly. For the first three days in Kailahun, he was conversant and able to move with relative ease. He would spend much of the morning and afternoon—when the heat and humidity built up to uncomfortable levels inside the isolation tent—in a small cordoned-off outdoor area, sitting and chatting with visitors across the orange-mesh barrier. “I was there every day, bringing him coconut water, a new charger for his cell phone, corn porridge for breakfast,” Kaima says. “Then Dr. Khan didn’t come outside for two days. He was not eating anymore.” A World Health Organization physician working with Doctors Without Borders told Kaima on the fifth day that Khan’s condition had suddenly gone critical. The doctor helped Khan outdoors that afternoon. Khan looked frail, with a hollow-eyed stare, but he could still sit up.

  “Doc, I know you are a fighter, you have to win this,” Kaima said.

  “Peter,” Khan replied, weakly. “You don’t know what I’m going through. This is not easy for me.”

  On July 28, Mohamed Sankoh-Yela, a nurse from the Kenema Government Hospital who had tested positive for Ebola the previous day, arrived for treatment in Kailahun. “Dr. Khan was not very strong, and he had frequent diarrhea,” Sankoh-Yela remembers. Still, he was able to sit up in bed and make small talk. He did not seem, the Ebola-stricken nurse recalls, as if he were anywhere near the point of death. At Tulane University, Garry had been receiving regular updates from colleagues in Kailahun. “We heard that he was feeling okay, he was doing fine,” Garry says. “We thought he had entered a critical period where if he makes it through the next few days he’d be out of danger.”