“Absolutely,” Kobinger answered. In fact, he said, he had planned to test the drug on himself if he had caught Ebola.
Anja Wolz spoke with Kobinger. “Gary, I don’t know what to do,” she said.
Wolz recalls that Kobinger said to her, “You are in an impossible situation. Any decision you make will be the wrong decision. But we stand behind you and the decision of the team.”
After talking with Gary Kobinger, Tim O’Dempsey presented his own view to Anja Wolz and the camp doctors and managers. He argued that Khan should be told about the drug’s presence in the freezer and should be offered a chance to take it. Khan’s risk of dying from Ebola far outweighed any risk the drug posed to him, O’Dempsey argued.
At this point, though, none of the camp’s medical staff, including the doctors present, would agree to administer the drug to Khan. It was a unanimous decision: Even if Khan asked for the drug, they wouldn’t give it to him.
Tim O’Dempsey had come to the camp with plans to give Khan medical help if he needed it. He asked Anja Wolz if he could put on PPE and enter the red zone so that he could meet with Khan and assist him. She told him that he could not.
As it turned out, Wolz had been one of O’Dempsey’s students at the Liverpool School. He got into a long, tough discussion with her and other camp managers as he tried to persuade them to let him go in and help Khan.
I made multiple requests to Tim O’Dempsey for an interview, but he declined them. However, O’Dempsey’s colleague at the Liverpool School, Dr. Tom Fletcher (the WHO doctor who had worked as an advance operative at the Kenema hospital) did have a comment. “Tim O’Dempsey had to negotiate hard before he was allowed to see Khan,” Fletcher said. “From the reports we got from Tim O’Dempsey, we felt Khan’s care could have been better. Most people I know think his care was far from optimum. It upset a lot of WHO staff.”
A Canadian doctor named Rob Fowler, who worked with Tim O’Dempsey at the Kenema hospital, said he could understand Anja Wolz’s position as well as O’Dempsey’s. The conflict between them was a matter of life or death. “Imagine you are a physician,” Fowler said, “and you walk up to Dr. Khan’s bed and say to him, ‘Dr. Khan, we need to have a discussion about your treatment options,’ and then you do a three-sixty and you see fifty other people in exactly the same position as Khan. How is that fair? Of course, I’m sure that Tim wouldn’t stop at giving treatment just to Dr. Khan. They would have had a hard time getting Tim out of there once they let him in.” Fowler said that he’d worked with O’Dempsey in the Kenema wards, and it had been really hard to persuade him to pull out of duty, even when he was exhausted and it was late at night.
Finally, the camp officials allowed O’Dempsey to put on PPE and go into the red zone to see Khan. But O’Dempsey was told that he must not tell Khan about the drug in the freezer.
A doctor has a duty to inform a patient of the treatment options that are available to the patient. If nobody at the camp would agree to administer ZMapp to Khan, then the drug wasn’t available as a treatment for him, and so the camp doctors had no ethical duty to tell him about it.
When international medical personnel went to work for Doctors Without Borders, they were informed that if any of them came down with Ebola, the person would be flown to Geneva, placed in a world-class hospital, and offered experimental drug treatment. The treatment, specifically, was human-grade Course No. 1 of ZMapp.
After O’Dempsey got permission to go into the red zone, he suited up and went in, and found Khan upbeat and smiling. Khan said he had a headache and body pains, but he still had an appetite. O’Dempsey asked if there was anything he could do for him. Khan asked for jelly coconut water.
ELWA HOSPITAL, MONROVIA, LIBERIA
Late morning, Wednesday, July 23
While the experts were starting to discuss treatment for Khan, Dr. Kent Brantly, the chief physician of the Samaritan’s Purse Ebola ward in the chapel at ELWA Hospital, made an exit from the ward. He passed through a decon line where Samaritan’s Purse volunteers, who were wearing bioprotective gear, sprayed him with bleach and helped him remove his gear. Once Brantly had gotten de-suited, he collected his phone and called the director of emergency medical operations of Samaritan’s Purse, Dr. Lance Plyler. Plyler was Brantly’s boss. “Lance, don’t freak out, but I think I’ve got a fever,” Brantly said to him.
Lance Plyler told Brantly to go home and isolate himself. Brantly lived in a whitewashed bungalow on the grounds of ELWA Hospital. He went to bed in his house. A nurse from Samaritan’s Purse visited him, drew a sample of his blood, and wrote a fake name on the blood tube, “Tamba Snell.” Plyler didn’t want anybody to know that the head Ebola doctor was getting a blood test. It was now about twenty-four hours since Lisa Hensley had been shifting boxes with Brantly inside a closed storeroom and talking with him, their faces inches apart.
NIGHTFALL
KAILAHUN ETC
Sunset, Wednesday, July 23
Hours later, as night fell over West Africa, Humarr Khan lay down in his cot for his second night in the camp. Unknown to him, the international conference call about him was still going on. Doctors with the World Health Organization were getting angry. They were strongly in favor of telling Khan about the ZMapp and giving him a chance to decide for himself. The camp officials opposed this idea and were seeking alternatives. Some managers at the Brussels office of Doctors Without Borders favored offering the drug to Khan, but they felt that the camp managers had authority. Anja Wolz didn’t want the camp’s staff and patients to be endangered by violence if Khan died. She was skeptical of the drug and afraid it would fail or kill Khan. The discussions were heated and impassioned.
Gary Kobinger, in Winnipeg, stayed on the calls and answered questions about ZMapp. Since he was one of the inventors of the drug, he couldn’t make a recommendation—it’s illegal for the developer of an unlicensed drug to advocate giving it to a human subject. “I tried to keep my voice neutral,” Kobinger recalled. He described how the drug had saved eighteen monkeys from death. Each animal had been given three doses of ZMapp, spaced a few days apart. He compared this to three punches from a prizefighter: The first two punches knocked Ebola down and the third ended the fight.
As the hours passed, WHO doctor Tim O’Dempsey agreed to administer the drug to Khan himself. If something went wrong, the WHO would get the blame from the Africans, not Doctors Without Borders. The plan became unworkable when camp doctors asserted that if O’Dempsey gave ZMapp to Khan they would not be willing to be involved in any aspect of Khan’s subsequent medical care. O’Dempsey couldn’t care for Khan by himself without any backup.
They came up with a new plan for Khan. At 10:45 p.m., West Africa time, Gary Kobinger, in Canada, sent an email to Larry Zeitlin, the president of Mapp Bio, who was at his office in San Diego. The two men got into a rapid-fire exchange.
KOBINGER: Ok there was no treatment today/night. WHO HQ is pissed but MSF [Doctors Without Borders] decided against. Just got more lab data, he could still be saved…Btw WHO is putting him on medevac, if he can last the ride.
ZEITLIN: Wow—they sending him to Geneva?
KOBINGER: Geneva, london, or france, whom ever accepts him.
ZEITLIN: So they aren’t planning to treat him with the Geneva dose?
KOBINGER: Sending him with 1 dose, rest will need to come from Geneva (or all 3).
The plan was this: A medevac jet would pick up Khan and fly him to some country in Europe. Tim O’Dempsey would travel on the jet with Khan. O’Dempsey would bring along one of the bottles of Course No. 2, the ZMapp at the Kailahun camp. He would administer the bottle to Khan during the flight. If the drug sent Khan into shock, there would be medical equipment on board the plane that might save him. If Khan survived and got to an advanced hospital in Europe, two bottles of Course No. 1—the Geneva course—would be flown to Khan. That way, Khan would get the req
uired three doses of ZMapp, and his treatment would occur outside Africa.
LIBERIAN NATIONAL REFERENCE LAB
8:30 a.m., Thursday, July 24
An Embassy vehicle picked up Lisa Hensley and her American colleagues at their hotel and took them on the hour-long drive to the national lab. By the time they arrived, a delivery of blood samples had come from Samaritan’s Purse at ELWA Hospital, an insulated box containing tubes of blood packed on ice. Each tube was packaged inside a plastic bag, and the bag had been sterilized. Hensley suited up and went into the hot area, and the team began testing the blood samples. One of the samples was from a patient named Tamba Snell. The name was common, and nobody thought anything about it. By the end of the day, the team had found that Tamba Snell was negative for Ebola. Hensley reported the blood results back to Samaritan’s Purse. At Samaritan’s Purse, when Lance Plyler learned that Brantly’s blood test was negative, he ordered a second blood test. Kent Brantly was still isolated at home, and he wasn’t getting better.
KAILAHUN ETC
Later that day
The discussions about getting a jet for Khan continued the next morning. Officials at the WHO headquarters in Geneva eventually hired an air medical company called International SOS to fly Khan to Europe. But France, Germany, and Switzerland wouldn’t immediately agree to allow a foreigner infected with Ebola to cross their frontiers. The SOS jet would need to land somewhere and refuel, perhaps in Mali or Morocco. No country would allow the jet to land on their soil if it was carrying a confirmed Ebola patient.
Tim O’Dempsey then proposed a different idea to Anja Wolz and the camp managers: He would take Khan back to Kenema himself. He would bring the camp’s supply of ZMapp with him. At the Kenema hospital he would personally administer the drug to Khan. If Khan was given ZMapp in his own hospital, Africans would be less likely to think he was the victim of a white experiment. This way, there would be no danger to the Doctors’ camp, and the Doctors wouldn’t have to breach their ethical code by giving the drug to Khan.
The camp leaders agreed to O’Dempsey’s proposal, but they stressed that he must not tell Khan about the ZMapp in the camp’s freezer. O’Dempsey went to the visitors’ area and talked with Khan across the red zone fence. He asked Khan if he would like to return to Kenema. Speaking vaguely, O’Dempsey said that it might be possible to offer Khan treatment in Kenema that wasn’t available at the Doctors’ camp. He didn’t say anything about ZMapp.
Khan didn’t want his staff to see him infected with Ebola. He told O’Dempsey that he had more privacy at the camp, and he would stay at Kailahun.
After that, Michel Van Herp approached Anja Wolz privately. He couldn’t stand to see what was happening with Khan. “I am going into the center to give the medication to Khan myself,” he said to Wolz.
Wolz recalls that she advised him not to do it. “I was like, ‘No, from an ethical position you shouldn’t do it.’ It was the most horrible situation I had ever been in with Médecins Sans Frontières.”
Same day
Michael Gbakie, who was keeping Khan’s passport for him, visited Khan regularly, speaking with him across the fence at the visitors’ area. Khan told Michael that he had come down with diarrhea and was getting dehydrated. He asked Michael for IV hydration—a drip of saline solution in his arm, to replenish his fluids.
The camp staff, feeling overwhelmed by the number of patients, and concerned about the dangers of a bloody needle, had stopped giving IV fluids to patients. Michael told Khan that he would come into the red zone and set up a saline drip for him. He thought the best thing for Khan would be Ringer’s solution, which has potassium in it. If Khan’s potassium got too low he could have a heart attack. Michael went in search of a camp official who would allow him to enter the red zone with an IV hydration kit and administer it to Khan.
He found a doctor and asked to speak with him for a moment. He told the doctor that Dr. Khan was getting dehydrated and needed IV hydration. He wanted to go in and set up a drip of Ringer’s for Khan.
The doctor answered that nobody was allowed to go in except staff of Doctors Without Borders.
Michael identified himself as Dr. Khan’s deputy, and said Dr. Khan needed assistance. He said he was very experienced with PPE.
Just then, the doctor happened to be with the camp’s logistician. The logistician, who is one of the most important officials at the camp, manages the supply chain and physical operation of the camp. The situation at the camp was dire, and the logistician seemed exasperated with Michael’s request. “Why is everybody focusing on Dr. Khan?” he said. And no, Dr. Khan could not have any extra treatment that wasn’t available to the other patients. The other patients were not getting IVs. Dr. Khan could not have an IV if the other patients weren’t getting them.
It seemed crazy to Michael. “Do you actually know what you are saying?” he said to the logistician. “If every patient has to be treated equally, okay. But do you know how many lives he has saved? And how many lives he will save if he is alive?” If an infusion of saline solution could save Khan, it would enable more lives to be saved.
Michael claims that after he asked the question, the two managers turned their backs on him and walked away without a word. He would not be allowed to go into the red zone with an IV hydration kit for Khan.
JUSTICE
KENEMA GOVERNMENT HOSPITAL
Six months later
I am sitting in Michael Gbakie’s office, not far from the Hot Lab. It’s a hot day in January, at the height of the dry season. A wind called the Harmattan has filled the air with dust blowing in from the Sahara Desert, and the sky is the color of a lion’s fur. The virus is still flickering in Kenema, but the great fire has died down. Sierra Leone is getting a thousand new Ebola cases a month, a number that is dropping rapidly. The virus is active in Kono, an area to the north of Kenema. The schools of Sierra Leone are closed. All over the country there are roadblocks, where soldiers and police officers point a digital thermometer at your forehead and ask you questions about where you’ve been and where you’re going. A Red Cross Ebola center has been set up not too far from Kenema, and the number of Ebola patients in the Red Cross center has been going steadily down. The Ebola wards at the Kenema hospital have been closed. There are no Ebola patients at the hospital. The general wards are full of patients, and the food vendors move quietly along the walkways.
Michael Gbakie has survived the passage of the virus. He is a quiet man, not tall, with a rectilinear face and an air of sensitive reserve. Through the window of his office I can see the Tent. It is empty.
“Do you feel the camp managers treated you with contempt when they turned their backs on you?” I ask.
He speaks calmly. “Of course, with contempt.”
“How did you feel? I mean, what were your emotions just then?”
His gaze drifts sideways, as if he’s looking away from something, not at something. “According to how I felt—at that time, emotionally, I had the impression on my face that I was not satisfied with his answer to my question. I didn’t shout. I was just a little bit calm. And they walked away. They said nothing, as if I was not somebody.”
“Were they white?”
“They were both white.”
“Do you feel this was racism?”
His answer surprises me. “No,” he says firmly and immediately. “It doesn’t sound like racism is the problem here.”
I am struck by this. “What is the problem, then?”
The problem, for him, wasn’t simple racism. The camp managers seemed insular to him, caught up in a rigid rule and rigid procedures that were interfering with the saving of lives. He was a medical professional engaged in the same fight they were engaged in. He had ten years of experience wearing PPE and managing care for hemorrhagic patients infected with a Biosafety Level 4 virus. He was making a point about justice in medicine, and he didn’t like be
ing ignored when he raised questions about their concept of justice.
* * *
—
“There’s been a longstanding problem between MSF and the local African healthcare community,” said John S. Schieffelin, a pediatrician at the Tulane University School of Medicine who had worked in the Kenema hospital during the crisis. “When I went up to Kailahun to talk with the European staff at MSF, I was treated one way and the African staff we partner with in Kenema were treated very differently. In Kenema, our African staff are treated as equals. The Europeans at MSF didn’t engage with our Kenema staff as colleagues. It’s wrong. It’s just wrong. They’re also trying to impose their version of justice on people who see it differently. We couldn’t even convince MSF of the use of IV hydration,” Schieffelin said.
At the time, the leaders of Doctors Without Borders believed that giving Ebola patients IV saline would not improve a patient’s chance of survival. They also felt it would expose workers to bloody needles—an unacceptable risk. When the number of patients surged in the treatment units of Doctors Without Borders, they halted or greatly reduced the practice.
“I find this difficult,” Tom Fletcher said, referring to the Doctors’ decision to stop giving IV fluids to Ebola patients, “because they didn’t administer much IV anyway. Anyone who has used IV fluids on Ebola patients cannot understand the rationale for not using it. At Kenema, we had two or three doctors for up to a hundred patients, and we gave IVs to everybody who needed one. Placing an IV doesn’t take that long and doesn’t present a high risk to a health worker. Various needles have a cap that flips over to make it safe. Getting people to sip oral rehydration by mouth is much more time-consuming because you have to sit there with the patient. It’s also more dangerous, because it’s close contact with the patient over a longer time, and the patient can vomit. The solution is not to ban IV use—then you get a case-fatality rate of seventy percent. With a willingness to use IVs, you can drop the fatality rate below fifty percent.”
Crisis in the Red Zone Page 28