The other reason Pardis Sabeti and Robert Garry couldn’t get help to Humarr Khan was because of a shortage of medical people who had training and experience at dealing with an outbreak of a Biosafety Level 4 hemorrhagic fever virus. There just weren’t enough knowledgeable doctors. Doctors Without Borders had taken the lead in crushing Ebola during past outbreaks. The Doctors knew how to set up an Ebola biocontainment ward and run it safely. They had biocontainment tents, they had spray pumps, laboratory equipment, generators, food, doctors, and robust supply lines, and they had a depth of operational experience with Ebola. And the Doctors were already stretched to their maximum. The medical world as a whole had no idea, no clue, how to stop an Ebola outbreak or how to safely handle patients infected with a huge, aggressive, Biosafety Level 4 virus.
“I’m worried about your stress,” Sabeti said to Khan. “The most important thing is your safety, Humarr. Please take care of yourself.”
“I feel I have to do all I can,” Khan answered. He asked her about the genome sequencing of Ebola. Was the virus mutating? Was it becoming more lethal than Zaire Ebola? Khan, Lina Moses, Mbalu Fonnie, and the nurses had been struck by the features of the Ebola disease in the Lassa ward. There seemed to be less bleeding, less frank hemorrhage, but there was a huge amount of vomiting and diarrhea. Lina Moses wondered if this new Ebola was more transmissible than Zaire Ebola, because the patients produced huge amounts of infective fluids, which got splashed and smeared all over the nurses’ protective gear. The patients did bleed from their gums, and their urine could turn bloody, but the nurses didn’t see nosebleeds. Of course there were expulsions of melena—hemorrhage—from the intestinal tract. Was there something different about this West African Ebola? Was it really the same as classic Zaire Ebola?
And finally, was it mutating? There was a widespread view among Ebola experts that Ebola virus doesn’t evolve in humans. Ebola, they asserted, was very unlikely to mutate significantly during an outbreak. Pardis Sabeti, looking at the Ebola code that had been collected from the twelve people in the Triangle, could see that the Ebola was, in fact, mutating. Its letters had changed, here and there, in the twelve Ebola genomes she was looking at. But there was no way to tell whether the mutations were just noise, only meaningless random stuttering of the Ebola genome as Ebola passed through people, or whether Ebola was evolving and getting to know people better.
Whatever the virus was doing, it was definitely a swarm. As of June 18, the growing swarm of Ebola particles in West Africa was still very small. Only about four hundred people, at most, were infected with the virus. Each infected body contained anywhere from a hundred trillion to several quadrillion particles of Ebola virus. In all, the swarm consisted of around forty quadrillion to a quintillion particles of Ebola.
A quintillion looks like this in digits: 1,000,000,000,000,000,000. It is a small number by the measure of a virus. A really small number. At this point, in the middle of June, the swarm was only the beginning of the entity it would soon become.
There are 18,959 letters in the Ebola genome, arranged in an exact spelling. As each particle replicated, there was a certain chance that an error in a letter would occur, and the spelling of the genome would change. Many of the changes in spelling didn’t change the character of the virus itself. But there were misspellings that could change the virus by a lot, very suddenly. The growing Ebola swarm could be thought of as a huge, invisible biological pachinko machine with a quintillion balls bouncing in it; a cloud-like, expanding entity that was flooding into the human species along many chains of infection, all the while making vast numbers of random tests of human bodies to see how best to penetrate them and move through them and make itself immortal in them. Sabeti and her colleagues felt a definite fear that the Ebola cloud could get a mutation that would change it very suddenly, and would make it better adapted to the human body. They were trying to make an image of the thing. And it had come from a child who had touched something that lived near his house and got a few of the particles in his bloodstream.
Khan was dealing with the entity. He told Sabeti that it was hitting his hospital hard, and that somehow he and his colleagues hadn’t seen it in Sierra Leone when it first arrived. “How could we have missed it? How could we have missed it?” Khan said to people over and over. He asked Sabeti if she could tell whether the virus was changing. She said that she and her colleagues were still analyzing the data. They didn’t yet know how the genetic code of Ebola was changing, or if it was changing significantly. As soon as she knew anything, she would tell him, she said. She urged him to keep himself safe.
KENEMA
Ten hours later
Before dawn on the morning of June 18, Dr. Azziz Jalloh, who was still working in the general wards, did regular rounds in the Annexe ward. There, he came across the ambulance driver Sahr Nyokor. Mr. Nyokor had been admitted with a suspected bleeding stomach ulcer. Dr. Azziz found the driver “in a tormented state,” as he later recalled. Nyokor was mentally confused and writhing with abdominal pain.
Dr. Azziz wondered if the man could have Ebola. But the symptoms didn’t add up. The driver had only a slight fever, and he hadn’t vomited once since his admission. No diarrhea, either. In fact he was constipated, and hadn’t had a bowel movement in two days. Dr. Azziz examined the inside of Mr. Nyokor’s mouth for telltale signs of Ebola. He was looking for inflammation inside the mouth or for hemorrhage coming from the gums. Mr. Nyokor’s mouth appeared perfectly normal. In fact, Mr. Nyokor was in the false dawn of Ebola and was about to die.
Despite the fact he couldn’t see any Ebola symptoms, Dr. Azziz had a gut feeling that the man had Ebola, and he ordered a blood test.
As Dr. Azziz examined the ambulance driver, a nurse was standing by. In this book she will be called Lucy May. (Her true name has been withheld for the sake of her family’s privacy.) Dr. Azziz gave some instructions to Lucy May about caring for Mr. Nyokor, and he left the ward at about six o’clock that morning.
Lucy May continued to care for Mr. Nyokor. She was thirty years old, a married woman with a delicate appearance, a devout Catholic who styled her hair in a modest bob. Lucy May had a beautiful singing voice, and she sang in the choir of St. Paul’s Cathedral in Kenema. Unlike many of the nurses, she had continued working in the Annexe ward even after other nurses had gotten fearful of the virus and had stopped coming to work. It is pretty clear that she stayed at her post supported by the strength of her religious faith.
About an hour after Dr. Azziz left the ward, at about seven a.m., Nyokor got out of bed and walked to the toilet at the end of the ward. While he was in the toilet, he had a bout of diarrhea—his constipation had suddenly ended. While he was in the toilet he collapsed and fell, and hit his head on something. Nurse Lucy went into the toilet to assist him and discovered that he was bleeding from a wound in his scalp. She cleaned the blood from the laceration on his head and got him back into bed. An hour later, Nyokor went into sudden shock and died abruptly.
We can imagine, but don’t know for sure, that Lucy May stayed with Nyokor as he died. The two were colleagues on the hospital staff, and she probably knew him personally, at least a little bit. It’s easy to imagine that when she realized that her colleague was dying she prayed for him, asking God to have mercy on him in eternity, and maybe she held his hand as he passed. A few minutes after the ambulance driver died, the nursing shift ended. It was eight o’clock in the morning, the time of the shift change, when the night nurses went off duty and the day nurses came on duty. Lucy May left the Annexe ward and went home to get some rest. She needed her rest, because she was pregnant and her baby was due soon.
BLOOD DRAWS
8 a.m., June 18
After Nurse Lucy May went off duty at the Annexe ward, a nurse named Iye Princess Gborie came on shift in the ward and took Nurse Lucy’s place. Nurse Princess was a tall, handsome woman, who would sometimes get a faintly skeptical expression on her fac
e, and she was a Christian. She wore a small golden cross around her neck on a golden chain. The ambulance driver had just died, and it was her responsibility to do the last offices for the body. Like Nurse Lucy, Nurse Princess had remained at her post as Ebola appeared in the general wards. If Ebola were to appear in the general wards of any hospital in the United States it would be a national emergency. It was the same at the Kenema hospital, a national emergency, and the nurses knew this. It’s why Princess Gborie had reported to work that morning, though by all accounts she was deeply afraid of the virus.
She closed the ambulance driver’s eyes. She may have known him personally or at least recognized him. If there was any remaining blood on the cut on his head, she might have wiped his head. Since she was a Christian she probably prayed for him. She arranged his limbs and tidied up his clothing, and maybe she washed his face. Having finished these small but important tasks, she covered his body with a cloth. About an hour afterward, a blood technician arrived and drew a sample of blood from the body. This was the Ebola blood test that Dr. Azziz had ordered a few hours earlier.
Sahr Nyokor’s blood was tested twice, once by Augustine Goba and his staff, using the Harvard PCR machine, and once by Nadia Wauquier and her staff, using Wauquier’s PCR machine. By late afternoon, both tests matched, and they revealed that the ambulance driver had died of Ebola. Augustine Goba sterilized and froze a half-teaspoon of Nyokor’s blood serum in a plastic vial. Two days later, this blood sample, along with a large number of other samples of Ebola-infected blood, was in the air over the Atlantic Ocean, on its way to the United States for genome sequencing at the Broad Institute.
* * *
—
As conditions in the Ebola ward and at the hospital got worse, Lina Moses virtually stopped communicating with her husband and daughters. She wasn’t the greatest communicator by email anyway, and phone connections between Kenema and New Orleans were bad, so it was hard to hear somebody talking. Moses really wanted to spare her family any vivid knowledge of the horror that was unfolding around her. Her initial expectations that the Ebola outbreak would be fairly small and manageable had not proved correct. She also didn’t want her loved ones to worry about her. She felt confident that she could keep herself safe. Meanwhile, in New Orleans, school was letting out for the summer. Aron was planning to take the girls on a summer road trip along the East Coast, to see Washington, D.C., and other places and sights.
On June 20, a British epidemiologist who had arrived to help trace the disease in the population noticed that Lina Moses was running back and forth in flip-flops through a crowd of people that gathered in front of the Ebola ward every day. Some of the people in the crowd had Ebola and were vomiting. He spoke to her about the flip-flops, and he was upset. “You are insane to wear those! You must wear rubber boots!” he said. Moses felt she couldn’t run in rubber boots, but she compromised by wearing a pair of old hiking boots. There were mud puddles in the dirt area in front of the Ebola ward, and as she walked through the puddles her boots got rinsed of Ebola particles, perhaps.
Moses was staying in a room at the Tulane guest house, a neglected structure with a verandah and a dead garden, on Hangha Road—a thoroughfare that runs north out of town along the base of the Kambui Hills. The Blood Diamond War had left the guest house in a state of decay, but it was comfortable and clean. It was surrounded by a high wall, and was protected by a security guard. A housekeeper named Jeneba Kanneh cooked meals and kept the house tidy. Moses’s room contained a bed with a mosquito net draped over it, a bureau, a lightbulb on the ceiling, and an electric fan on the floor, pointed at the bed.
Moses had almost stopped communicating with her husband and daughters. There’s this thing called Ebola here, she had written in an email to them, but she hadn’t really explained it. She couldn’t explain to them what was happening in Kenema or how she felt about it. She wore a locket around her neck that held pictures of her young daughters. Lying in bed in her room in the guest house, late at night, after another impossible-to-describe day of carrying supplies to the Ebola ward and carrying tubes full of infected blood back to the Hot Lab, Lina Moses would open up the locket on her neck and look at the faces of her daughters. Someday, would they remember her as their mother who was always gone, their missing mom? Or would they remember her as an example, a hero? All she knew was that she couldn’t leave Kenema now, no matter what happened.
TULANE GUEST HOUSE, KENEMA
7 a.m., June 22
A day after the epidemiologist forced Lina Moses to get rid of her flip-flops, Jeneba Kanneh was working in the kitchen of the Tulane guest house. She had put hot water in a thermos for instant coffee and some bananas and mangos and breakfast cereal on the dining table in the parlor. She heard Moses’s bedroom door bang open and Moses running into the bathroom and being violently sick. Kanneh went to the bathroom door and asked Moses if she was all right.
“It’s nothing,” Moses answered through the door.
After a while, Moses went back to her bedroom. But then she ran to the bathroom and got sick again. After she’d returned to bed, the housekeeper went to Moses’s door and asked, again, if she was feeling all right.
“I have a touch of something.”
About an hour later, Nadia Wauquier arrived at the Lassa Laboratory. When she looked into the Library—the crisis operations center—she saw that Moses wasn’t there. This made her feel slightly concerned. Lina Moses had recently had a bout of malaria, but even when she’d been feverish and shaky with malaria she had kept on working in the crisis center. What would take Lina away from work? Nadia started asking around: Had anybody seen Lina?
Nobody had seen her.
Nadia sent Lina a text: Where are you?
A text came back: Not feeling perfectly well. Lina added that she would be staying home for the day.
This didn’t worry Nadia, not very much. This is Lina’s malaria coming back, she thought. She went across the hall to the entrance of the Hot Lab and put on PPE, and then went inside the Hot Lab and began preparing blood samples for the day’s Ebola testing. Hours went by while Nadia worked in the Hot Lab. Then she de-suited and exited, and transferred her samples to her cargo-container lab and began processing them in her PCR machine.
As she worked, Nadia glanced at her phone once in a while. She was hoping to see a text from Lina with an update on her illness, but there was nothing. Lunchtime passed. Then came afternoon and there was still no text from Lina. Nadia noticed that the Sierra Leonian staffers were very aware of Lina’s absence. They were obviously wondering if she was sick, and they seemed worried about her.
The afternoon dragged on. At 2:59 p.m., Nadia got a text from Lina: I’m pretty sure I have a fever now.
Nadia believed this was nothing serious. It had nothing to do with Lina’s flip-flops, or her habit of walking into the foyer of the Ebola ward without biohazard protection, Nadia thought. Lina probably had a stomach bug. But…in case. Just in case. She should probably test her blood. Very quietly. If people found out that Lina…
Lina had seemed invulnerable, untouchable. She claimed to know where the virus was. Maybe Lina hadn’t known where it was. It would be necessary to get a sample of Lina’s blood. Nadia didn’t know how to do a blood draw. She would need to find a blood technician who would do the draw secretly and wouldn’t talk about it afterward.
Nadia exited the Hot Lab and found a blood technician named Hassan Katta. Katta was a friend of Lina Moses. He agreed to do the blood draw and keep it a secret. Working discreetly, Nadia and the tech loaded a set of PPE into the vehicle and drove to the Tulane guest house, into the walled compound, and parked behind the house, as close to the back door as possible. Some of the neighboring houses had lines of view going into the yard. If any neighbors saw a man wearing a white moon suit going into the house, it could set off a panic in the neighborhood.
Nadia and Katta opened the vehicle�
��s doors, to further block the view. Standing between the vehicle’s doors, Katta stepped into a whole-body Tyvek suit and zipped it up. He slid his feet into rubber boots, and put on a HEPA breathing mask, eye protection, and gloves. He opened a blood kit and took out a venipuncture needle and a Vacutainer red-top blood collection tube.
Nadia noticed that the needle was shaking in Katta’s hands. He was extremely nervous.
They had brought only one set of PPE, so Nadia stood just outside the back door. She looked into the parlor, which was a large room with nothing in it except a dining table and some chairs. Lina’s bedroom door was to the right of the parlor, and was closed. Katta entered the house, knocked on Lina’s door, and went in.
He found the room flooded with sunlight and very hot. The curtains were wide open, and an electric fan sat on the floor, blowing air toward the bed. Lina was lying on the bed. She was conscious and very sick. Her face was flushed and pouring with sweat, and her shirt was saturated with dark patches of perspiration. Katta had forgotten to bring a thermometer with him. He put his gloved hand on her forehead and estimated that her temperature was 103 to 104—dangerously high. He got a tourniquet ready.
TULANE GUEST HOUSE, KENEMA
About 4 p.m., June 22
Katta’s hands were shaking, and Lina Moses didn’t like that. “I can pull the tourniquet,” she said to him. She sat up and wrapped the strip of rubber around her arm and tightened it, and then watched as Katta tapped his gloved finger on her arm, feeling for a vein. He uncapped the needle. When the bare needle appeared, his hand started shaking again. He pushed the needle into her arm, but his hand was trembling and he missed the vein. He pulled out the needle and apologized. The needle was bloody and dancing a little. He inserted the needle a second time and again missed the vein. This triggered a bleed under the skin of Moses’s arm—he’d put a hole in a vein, and a goose egg of blood rose up on her arm. Katta was very apologetic.
Crisis in the Red Zone Page 16