Robert Garry needed to use the equipment, and he worked at night, when the lab was less busy. Yet as time went by it became increasingly difficult for him to work ethically in the Hot Lab doing research, when the first priority had to be testing blood in order to save lives. In a few days, however, Garry collected scientific blood samples from forty-nine suspected Ebola patients.
The result was a large number of microtubes of human blood serum. Blood serum is a clear, golden liquid. It contains everything in blood except for the red cells, which have been removed. Each microtube was the size of the sharpened end of a pencil and contained a droplet of human blood serum no bigger than a lemon seed. The drops each contained anywhere from a few hundred million to a billion particles of Ebola virus. The genetic code of the new Ebola was present in the droplets, and was unread and unknown. The droplets were mixed with a larger quantity of a sterilizing chemical that kills Ebola, and were then frozen. Augustine Goba packed the tiny tubes of sterilized blood serum on dry ice inside a box, and sent the box by international courier to Harvard.
CAMBRIDGE, MASSACHUSETTS
June 4
Four days later, the box arrived at Sabeti’s lab in Harvard’s Northwest Building, where a research scientist named Stephen Gire put on bioprotective gear and carried the box into a tiny biocontainment lab to open it. The samples were supposed to be safe, but Gire was taking no chances.
Gire is tall and quiet, and there is an air of seriousness and precision about him. After he’d gone into the biocontainment lab with the unopened box of blood samples from Africa, he realized that he had forgotten to bring along a knife. He opened the zipper of his suit, fished his car keys out of a pocket, and slit open the box. The ice had melted, but the tubes were still cold, and they were visibly safe: The color in the tubes confirmed that the blood serum had been sterilized.
Gire’s first job was to extract from the blood serum the virus’s genetic material, and test all the samples for the presence of Ebola virus. Of the forty-nine people whose blood samples were in the tubes, fourteen had been infected with Ebola. He could tell just by looking: In those samples, the virus had damaged the blood, and the serum had a murky look, clouded with dead red blood cells. Gire worked late, spinning all the tubes in a centrifuge to clarify the liquid in them. He added alcohol to the samples, and other chemicals. The Ebola particles in the liquid fell apart, their protein cores breaking up, and the RNA in their cores unspooled and came out, drifting like invisible hair in the liquid. Using a pipette, which is a push-button instrument that is used for transferring extremely small quantities of liquid from one place to another, Gire moved drops from tube to tube. The strands of RNA in the liquid were delicate and brittle, like glass. As the drops were moved around, the strands of RNA shattered into short threads.
When Gire was finished, he had fourteen small, clear droplets of water solution, each in its own tube. Fourteen raindrops taken from fourteen individuals who had had Ebola, all of whom had lived in the Makona Triangle. In each droplet were vast numbers of broken strands of RNA—shattered fragments of genetic code of the Ebola that had once drifted in the blood of the fourteen people. There were many different genomes in the tubes, for the virus had mutated as it multiplied.
The next morning, Gire took a car to the MIT campus, carrying a small box containing the fourteen samples of droplets with the Ebola RNA in them. He parked and carried the box to the Broad Institute. There, Gire and a colleague named Sarah Winnicki, working alongside two other research teams, prepared the RNA to be decoded. The work took days, and was conducted in a glass-walled group of clean rooms inside the Broad Institute. Gire and Winnicki hardly slept as they worked on the drops, getting the liquid ready for processing in a genome sequencing machine, which would read the code of all the Ebola that had been collected from the Makona Triangle. They worked with fourteen droplets separately at first. Then they combined the droplets, merging the Ebola code from the fourteen people into a mixture.
Pardis Sabeti stayed in touch with Humarr Khan, giving him progress reports. He wanted to know how the decoding was going and how soon it would be finished. Information about the virus’s code could perhaps tell him just exactly what kind of Ebola he was dealing with in Sierra Leone or how it might be changing as it entered the human species.
Sabeti told him that they didn’t have a readout yet, but as soon as she got any code from the test she was going to publish the results on the Internet, so that scientists everywhere could get a glimpse of the Ebola swarm as it changed in time. If anything significant showed up in the code, she would let him know right away.
FLIP-FLOPS
EBOLA WARD, KENEMA
Early June
While the scientists at the Broad Institute were working with the droplets inside the clean rooms, the situation inside the Ebola ward was deteriorating. The beds were full, and as some patients died, more arrived. Auntie stood at the entrance of the ward, issuing instructions to her nurses in a whispery, British-accented voice, sending and receiving messages through staff, and sometimes putting on hazmat gear and going into the red zone to help the nurses and manage things.
The Tyvek material of the suit didn’t breathe. The nurses got boiling hot and soaked with sweat inside their suits. In the tropical climate, you couldn’t wear a whole-body PPE suit for more than about an hour before you were in danger of having heatstroke, which could be fatal. Auntie sent her nurses into the red zone in pairs, using a buddy system. A pair of nurses was a “hot team.” While the hot team worked inside the ward, a nurse sat outside the red zone and watched a clock. At the end of an hour, the clock-watcher would order the hot team to make an exit, and another hot team would be sent into the red zone to work. This was like sending scuba divers into a dangerous operation and timing their dives.
The nurses were trying to be meticulous in their safety precautions, but they were getting scared. They didn’t have any immunity to Ebola. The patients did not seem to be hemorrhaging much, but they were having explosive diarrhea and projectile vomiting. The ward was a mess. The suffering of the patients, and the way patients who seemed stable would suddenly crash and die in minutes, filled the nurses with horror and fear. Meanwhile the nurses’ families were getting scared. The nurses were going home after working inside the Ebola ward, coming into contact with their children, their spouses, their parents. Many family members urged the Ebola nurses to stop working, and some of the nurses began skipping work, not showing up for their shifts. This tormented Auntie.
Downhill about fifty yards from the Lassa ward, in the Library room in the Lassa Laboratory building, Lina Moses was running the crisis operations center. The Library was directly across the hall from the entrance portal to the Hot Lab, and she could see the lab people going in and out, putting on gear and taking it off. The Library was stacked from floor to ceiling with boxes of biohazard suits and safety supplies. Moses sat at a table, taking and making calls on a cellphone, typing emails on her laptop, and meeting with a constant stream of lab technicians, staff workers, janitors, and surveillance officers. She often went on errands across the hospital grounds, and she usually ran, carrying medical supplies and safety gear uphill to the Ebola ward, and running back downhill carrying tubes of blood from the Ebola ward to the Laboratory building. She would hand the blood to somebody at the entrance of the Hot Lab.
Moses wore plastic flip-flops on her feet. She felt she needed to run from one place to another: There was always some emergency happening and somebody needing something fast. It was clear that Moses should not have been wearing flip-flops. She should have worn heavy rubber biohazard boots, especially when she went anywhere near the Ebola ward. A crowd of sick people and their relatives milled around the entrance of the ward, and some were infected with the virus. There were body fluids on the ground in front of the ward, vomit and feces. Moses refused to wear biohazard boots, because they wouldn’t allow her to run. The flip-flops exposed the s
kin of her feet to the environment. She often ran up to see Auntie in the Ebola ward, her flip-flops slapping. Moses felt that she could tell where Ebola was and where it wasn’t. Carrying a load of biohazard suits in her arms, she glanced at the ground and stepped carefully around messy spots, trying not to get anything on her bare feet. If a person looked unwell, she tried to stay six feet away.
Nadia Wauquier, who was working inside the Hot Lab and running blood tests with her PCR machine, became increasingly worried about Lina Moses. The two women were close friends. Nadia thought Lina had stopped paying enough attention to her personal safety in her efforts to help Auntie. Lina was always running to the Ebola ward, and her flip-flops really made Nadia nervous. She thought that if Lina got a small cut in the skin of her foot, or got a little bit of blood or vomit on her foot, she could end up getting infected. She decided not to say anything to Lina about her flip-flops, though. She had to trust that Lina wouldn’t do anything stupid.
Humarr Khan was spending his time managing the crisis—hurrying around the grounds, rounding the general wards searching for patients with symptoms of Ebola, meeting with Auntie, meeting with the lab staff, meeting with the hospital’s other doctors, meeting with families of patients, trying to encourage Auntie’s Ebola nurses to keep going into the red zone. He worked closely with the district medical officer, an energetic doctor named Mohamed Vandi. Khan and Vandi were calling the Ministry of Health in Freetown, begging for more supplies, more assistance, more money.
The Ebola nurses were earning five dollars a day risking their lives in the Ebola ward. Khan and the district medical officer Vandi began asking the Ministry of Health for more money for the Ebola nurses. Government officials eventually agreed to provide each Ebola nurse with an extra $3.50 a day in hazard pay. But the money didn’t show up. It was just a promise. Khan began to fear that the money was getting embezzled through corruption, or that the government bureaucracy couldn’t be troubled to actually find any money for his nurses.
Khan and Vandi looked for international help, especially for more doctors who had any experience with Ebola patients. It turned out that there are very few doctors in the world who know anything about how to treat biohazardous patients who are hemorrhaging and rocket vomiting with a Level 4 virus. Khan got in touch with his friend Dan Bausch (who had talked him into taking the directorship of the Lassa program). Bausch was then working with the World Health Organization at a hospital in Conakry, Guinea, helping set up Ebola wards and bringing volunteer doctors into the fight as quickly as possible. Khan asked Bausch for help, and Bausch promised to send a WHO doctor to Kenema immediately. Bausch also promised to send additional WHO Ebola doctors in a few weeks, as soon as he could possibly get some. He added that he would also go to Kenema to help his friend Khan as soon as he could.
* * *
—
On June 8, Dan Bausch’s first WHO doctor arrived at the Kenema hospital. A Land Cruiser stopped in front of the Ebola ward, and a rugged-looking thirty-something man with a shaved head and a sparse beard stepped out of the vehicle and asked for Humarr Khan. He was a British doctor named Tom Fletcher, a virus researcher at the Liverpool School of Tropical Medicine, in Liverpool, England. Fletcher, an expert in delivering clinical care in Ebola outbreaks, was volunteering for the WHO as a kind of advance special operative. He went into chaotic, Ebola-ridden hospitals ahead of the Ebola doctors, where his mission was to stabilize the hospital and make it safe for the Ebola doctors who would follow him. Fletcher was carrying a single box of medical supplies. “I was worried about Khan. I knew he was getting tired,” Fletcher later said.
Khan arrived, and the two doctors talked briefly. They had never met. Fletcher sized up Khan quickly, and thought he seemed competent and dedicated. The two men then went into the Ebola ward to have a look, first suiting up in the cargo container staging room, where they inspected each other’s hazmat gear. Fletcher noticed that Khan wasn’t perfectly smooth at putting on his gear. Then they went through the door into the red zone.
There were fifteen Ebola patients in the cubicles along the narrow corridor. Fletcher could see that the nurses were under pressure. “They were a pretty frightened, tired group,” he recalled later. Khan told Fletcher that some of the Ebola nurses had been skipping work. They were afraid of catching the virus, and their family members had been pressuring them to stay home so they wouldn’t infect their families.
Patients were prostrate, and they were vomiting and having diarrhea. The nurses were giving them fluids to drink, but the patients vomited them up, which caused the patients to become severely dehydrated. As this happens, the level of potassium in the bloodstream decreases drastically. An imbalance of potassium in the blood can trigger a heart attack.
Khan was very concerned about keeping the Ebola patients hydrated. For years in his own practice he had prescribed coconut water to his patients. Coconut water was cheap, poor people could afford it, and it was rich with salts and minerals. But the patients were having trouble keeping liquids down, and kept throwing them up.
The alternative was to give an Ebola patient an intravenous infusion of saline solution, which could quickly bring the patient’s fluid and potassium levels back to normal. There was plenty of saline on hand at the Ebola ward, with plenty of infusion kits. But to put a needle into an Ebola patient’s arm seemed extremely dangerous—the worker could get pricked. The Ebola teams from the International Red Cross and Doctors Without Borders didn’t ordinarily give IV saline infusions to Ebola patients—the procedure was thought to be risky, because a medical worker could get stabbed with a bloody needle. Khan and the nurses were following a standard international policy of not using needles in the red zone.
Tom Fletcher had a trick for setting up an IV safely. He showed the nurses a technique for safely placing an infusion needle in an Ebola patient’s arm without endangering the nurse. The trick consisted of flipping a plastic cap over the needle so it wouldn’t prick you. From that day on, and with Khan’s encouragement, the Kenema Ebola nurses began giving IV saline infusions to all Ebola patients. “The nurses were phenomenal, really,” Fletcher said. “They were trying to deliver high quality care, sticking IVs into everybody, doing their absolute best for the Ebola patients.” It gave him a sense of confidence. “I was pretty hopeful. ‘This is pretty good,’ I thought.”
That evening, Fletcher and Khan got dinner at a hotel in town, drank a beer, and worked on a strategy to stabilize the Ebola ward. After dinner, the two men returned to the hospital, put on PPE, went into the Ebola ward, and worked into the night.
Days went by. Khan suited up and rounded the red zone, and he and Fletcher worked together. Every evening, the two doctors ate dinner at a hotel, drank a beer, planned action, and returned at night to continue working. Fletcher’s respect for Khan grew. They became friends. Meanwhile more and more Ebola patients kept arriving, including children. Auntie kept bringing in more cots, until the ward got so jammed with cots that it became difficult to move around. Patients were dying in the beds and in the cots, and the nurses were putting the bodies into biohazard body bags and removing them. Then there was the problem of food. The patients, especially children, needed to eat, if they could hold down food. Khan and Fletcher worked on providing a steady supply of food to the ward.
Khan and Fletcher remained optimistic that they could get things under control, but there wasn’t any way to control the virus outside the hospital. Four days after Fletcher’s arrival, there were twenty-five Ebola patients in the ward. Furthermore, Fletcher and Khan knew that there were additional undiagnosed Ebola patients hidden in the hospital’s general wards. The symptoms weren’t always obvious. Ebola was a disease with different faces, and in its early phases it could look like malaria or dysentery. As Khan went on his morning rounds, he kept finding people who had the symptoms of Ebola. He ordered blood tests, and some of the patients tested positive, and were sent into the Ebola ward.
The nurses in the general wards—who had no biohazard protection and zero training in it—couldn’t tell who had Ebola and who didn’t. To the general nursing staff, it seemed as if the virus could be anywhere at the hospital, or everywhere.
It was clear that the Ebola ward wasn’t large enough to hold the growing number of patients. Khan and the district medical officer Vandi began work on constructing a plastic tent that had been donated to the hospital by Doctors Without Borders. Just as the structure was being finished, a rainy-season thunderstorm destroyed it. Khan and Vandi immediately set out to build a larger tent. In the meantime the Ebola ward got packed. Lina Moses was running around in flip-flops tending emergencies. She got too busy to take her malaria pills, and she broke with malaria. Shaky and feverish, Moses continued to manage the crisis center. Michael Gbakie and Lansana Kanneh, prowling around the Triangle in ambulances, continued to find and bring in fresh Ebola patients. Tom Fletcher and Humarr Khan began to fear that they weren’t going to be able to stabilize Kenema Government Hospital. And then nurses who worked in the general wards began leaving their posts, becoming fearful that the virus was getting into the general wards. The general staff had started abandoning the hospital.
Crisis in the Red Zone Page 14