Crisis in the Red Zone

by Richard Preston

  Tom Fletcher worked for a time at Donka Hospital in Conakry, Guinea. The Donka hospital staff gave IV hydration to all Ebola patients who were dehydrated. One day a physician from Doctors Without Borders, who’d been working at the Doctors’ Ebola Treatment Center in Guéckédou, visited Donka Hospital. “She started weeping as she looked around,” Fletcher recalled. “She said to me, ‘How can the disparity of care exist between where I work [at the Doctors’ unit] and here in this hospital? We can’t utilize our skills at IV because of a policy.’ ”

  When a doctor is working in a disaster, doesn’t the doctor have a duty to help as many patients as she can, even when she can’t help everybody? This is the practice of triage—of deciding which patients to treat first when you can’t treat all of them immediately. Physicians commonly practice triage in a disaster. They work on as many patients as they can, even when they must leave some patients without care.

  “Of course it is justice to give IVs to some people and not to others,” Tom Fletcher went on. “It’s crazy to say nobody gets an IV just because some people can’t get it. That is madness.”

  BRUSSELS

  Summer 2015

  Dr. Bertrand Draguez, the clinical director of the operational center of Doctors Without Borders in Brussels, is sitting in a conference room at the center’s new headquarters, a modern building tucked along the Rue de l’Arbre Bénit (Street of the Blessed Tree). “The staff was basically parachuted in,” he says, referring to the Kailahun treatment center where Khan was placed. “Think about what it’s like for them. They may not know the difference between a baby in a bed, a pregnant woman in a bed, and a clinician in a bed. Their baseline view of the world is that all of our patients are equal.”

  Bertrand Draguez has red hair and hazel eyes and a youthful face dusted with freckles. He wears jeans and sneakers, and he has an informal, modest manner. The walls of the meeting room are made of pressed chipboard, the same cheap material that’s used in the construction of the organization’s medical treatment units. In 1999, Doctors Without Borders was awarded the Nobel Peace Prize for its humanitarian work. The organization delivers medical care to people in crisis—in conflict zones, and in places where a hidden emergency is occurring but the world doesn’t notice. The organization is sustained by small donations, and it spends around $1.4 billion a year in funds. On this day, the halls and offices of the headquarters were piled with cardboard boxes. The staff members were just moving into their new offices.

  “Think about the staff at Kailahun,” Dr. Draguez continues. “They don’t know Dr. Khan; they’ve never been to Kenema. Khan’s colleagues from Kenema immediately slot him into a higher level of care. For them it’s a no-brainer. But when you go into another microculture”—the culture of Doctors Without Borders—“it may be another story. We also shouldn’t forget that an ongoing outbreak may destroy your ability for reflection.”

  The camp managers were isolated, under siege, not sleeping, beyond exhausted, traumatized by all the deaths occurring in front of them, at risk of being infected, and they felt exposed to danger of attack from the local population. They were making life-or-death decisions in the fog of a virus war.

  On Friday, July 25, the International SOS jet for Khan landed at the international airport in Freetown. It parked near the terminal, waiting for him to be brought on board. By now, Khan had developed diarrhea and was vomiting. When officials at SOS learned that Khan had these symptoms, they said the plane wasn’t equipped to manage a seriously ill Ebola patient, and Khan would be a danger to the crew. Tim O’Dempsey began negotiating by phone with SOS, along with WHO officials in Geneva, and the camp manager Anja Wolz—all of them trying to persuade SOS to take Khan. But the company remained firm: Khan was too sick to be allowed on the plane. Sometime during the day, camp managers informed Khan that he would not be evacuated to Europe, and that, therefore, he would not have access to experimental drug treatments. By then, they had made a final decision that they would not inform him of the ZMapp in the camp freezer.

  That afternoon, while the jet sat at Freetown, Khan’s brother Sahid started making calls to Doctors Without Borders. He had been trying to reach Humarr for days. The family was frantic with worry about him. They knew he was in the camp at Kailahun, but they had no idea what was happening or even if he was alive. Sahid eventually reached someone at the Kailahun camp, and he demanded to speak with his brother.

  “He’s too tired to talk,” the person who answered the phone said.

  Sahid thought his brother was dead. He kept calling around, and finally he reached Michael Gbakie. “What is your name?” Sahid demanded. “What is your location?”

  Michael explained that he was Khan’s deputy and he was at the camp.

  “Nobody’s telling me anything!” Sahid burst out. “How is he? What is our plan?”

  Michael explained that a medical jet had arrived in Freetown. There was some sort of holdup, but the government of Sierra Leone was still trying to fly Khan out, possibly with a different medevac company. “The minister of health told me that they are going all out for aircraft.”

  “Is he alive?” Sahid said. “I want a picture of him to prove he is still alive.”

  Michael promised to take a picture of Humarr, and signed off. He then went to the visitors’ area next to the red zone, where he found Khan sitting in a plastic chair by the fence. Michael snapped a picture and texted it to Sahid.

  In the photograph, Khan is sitting slumped on the chair. His face is swollen, his eyelids are heavy and puffy, his expression is masklike. He appears to be exhausted and turned inward, though a slight smile flickers on his face. Sahid now thinks his brother’s smile may have been for the sake of their mother, an attempt to tell her not to worry.

  FATHER AND DAUGHTER

  FREDERICK, MARYLAND

  5:30 p.m., Friday, July 25, 2014

  Hours after Michael Gbakie took the picture, Lisa Hensley was in her hotel room in Monrovia, where it was 9:30 at night. It was pouring rain. She was looking at James on the screen of her laptop. The Skype call had gone through. James’s face was jaggy and freezy, but at least she could see him. Her mother, Karen Hensley, was sitting by James.

  “Grandma’s driving me crazy,” James said.

  “What’s she doing?” Lisa asked.

  “She’s telling me no all the time.”

  “Well, James is driving me nuts,” Grandma said good-humoredly. “Too many requests for snack food.”

  Grandpa never said no, James insisted. Grandpa was making him chocolate chip pancakes for breakfast with maple-flavored sausages and lemonade to drink. Lisa thought her father’s breakfasts were a little questionable, but she didn’t say anything. She asked James how his day had gone at summer camp. She reminded him she’d be home soon—her tour of duty was getting close to its end. She told him she’d see him soon, and said goodbye.

  Immediately afterward, Hensley took up her U.S. government secure cellphone and called her father. Mike Hensley was in another room in the house, in a place where James and Grandma couldn’t hear him. Lisa and her father began talking, and their conversation was dead serious.

  Mike Hensley, MD, PhD, is an expert in clinical trials and the licensing of vaccines and drugs. Working for the company that is now called Sanofi Pasteur, he had brought several childhood vaccines through clinical trials and licensing for human use. He had also participated in a clinical trial of an experimental antibody drug for cancer: He knew something about antibody drugs. In mid-July, Mike Hensley had begun focusing on the fact that healthcare workers in West Africa were dying of Ebola, and there was no vaccine or drug to protect them. He got involved with an effort to set up clinical trials in West Africa of Ebola drugs and vaccines in order to rush them into licensing.

  Mike Hensley discussed the matter with Pardis Sabeti at Harvard, and he brought in an expert on regulations of clinical trials. He got to
know the three inventors of ZMapp, Gary Kobinger, Gene Olinger, and Larry Zeitlin. By the evening of July 25, Mike Hensley had come to believe that the two best options for clinical trials were the VSV-ZEBOV vaccine and ZMapp. He and Lisa had started having twice-daily phone meetings about the project.

  Now, Mike and Lisa had a swift, businesslike exchange of information. There was no emotion in their voices. If you had heard the call, you would have assumed it was merely two scientists talking with each other, and you would never have known it was a father and his daughter.

  Mike told Lisa that Larry Zeitlin was sending him a large package of documentation on ZMapp. He intended to incorporate it into a plan for a clinical trial of ZMapp in Africa with Africans. He told her about some of the plan’s fine points.

  Lisa gave her father a report on the situation in Monrovia. The hospitals were filled with Ebola patients. More patients kept coming to the hospitals, and the hospitals were now turning people away even when they obviously had Ebola. Dead bodies had started to show up on the streets. Civil order was starting to break down.

  They signed off. Neither of them said “I love you” at the end of the call; it was something understood. “Stay safe,” Mike said to his colleague and daughter.

  If Lisa broke with Ebola, her colleagues would do everything they could to get her evacuated to the United States. But their efforts could easily fail. The U.S. government didn’t have any plans for evacuating personnel who came down with Ebola. If an air evacuation couldn’t be arranged quickly, Lisa could end up trapped in a horrifying Ebola ward, with no medical care. Mike Hensley wanted a trial of ZMapp started in West Africa for humanitarian reasons. At the same time, though, he hoped that a trial of ZMapp would get the drug positioned somewhere near Lisa in case she needed it. He said nothing to Lisa, her mother, or to the inventors of ZMapp about this thought; he kept it entirely to himself. “I wanted some kind of treatment on the ground for her,” he later said.

  MONROVIA, LIBERIA

  6 a.m., Saturday, July 26

  It was still raining when Hensley got up the next morning, but she wore James’s sun hat to the breakfast table. The hat was a hope for sunshine. The lab wasn’t staffed that day—it was July 26, Liberian Independence Day, a national holiday. Nevertheless, Hensley, Randal Schoepp, and a third American scientist took an Embassy car to the national lab, where many blood samples were waiting for testing. Among them was a second blood sample taken from the patient Tamba Snell at Samaritan’s Purse, who had tested negative the day before. There was also a tube of blood from a patient at Samaritan’s Purse named Nancy Johnson. Soon Hensley got an email from someone at Samaritan’s Purse: “Tamba Snell” and “Nancy Johnson” were members of their medical staff.

  They started with the blood of Tamba Snell, and found he had Ebola. In early afternoon Hensley sent an email to Samaritan’s Purse: “I am very sorry to inform you that Tamba Snell is positive.” Later that afternoon the Nancy Johnson blood also came up positive.

  At ELWA, Lance Plyler went to the house where Kent Brantly was isolated, in bed, and was distressed to see how ill he looked. “I hate to tell you that you have Ebola,” he said. After a moment, Brantly said, “I really did not want you to say that.” Plyler immediately decided that he would do all he could. He knew that there were experimental drugs for Ebola. Doctors from Samaritan’s Purse sent an email to the top CDC official stationed in Monrovia, a doctor named Kevin M. de Cock: They told him that they wanted to talk to a researcher with direct experience in the development of the drugs. They wanted that person to put Lance Plyler in touch with anyone who might have access to these possible therapies.

  After she finished up at the lab, Hensley dropped by a party at the house of an Embassy official. She stayed away from alcohol and watched her phone. Around eight o’clock she got an email from the CDC official Kevin de Cock. He said that Samaritan’s Purse wanted to talk with a scientist who had direct experience with the development of experimental drugs for Ebola. Samaritan’s Purse wanted to speak with just one person—only one person—about the drugs. De Cock asked Hensley if she’d be willing to serve as the advisor to Samaritan’s Purse.

  Minutes later, Hensley was riding in an Embassy Land Cruiser on its way to ELWA Hospital. The driver went fast along dark streets. Security was deteriorating in the city, and an attack or a hijacking wasn’t out of the question. The driver was under orders to not allow Hensley to step out of the vehicle unless there were security guards present at the location.

  The driver turned off the road and stopped at the entrance of the grounds of ELWA Hospital. The area was an empty field of grass and weeds, and was poorly lit. There were no security personnel visible. A pickup truck was parked near the gate, its headlights shining. Hensley’s driver went into a three pointer and positioned the Embassy vehicle for an escape.

  The truck’s door opened and a white man stepped out. He had a gaunt, unshaven face, dark hair, high cheekbones, and a mustache with a soul patch. Hensley’s driver didn’t like the look of the man, and told Hensley to stay inside the vehicle. After hesitating, she opened the door and got out.

  MILKY WAY

  ELWA HOSPITAL

  9:30 p.m., Saturday, July 26

  The gaunt man was Dr. Lance Plyler, the head of emergency medical operations for Samaritan’s Purse in Liberia. Hensley climbed into his truck, and he drove through the compound while the Embassy driver followed Plyler’s truck. They arrived at a small house, where a lighted window was opened just a crack. Kent Brantly was sitting in bed behind the window with his laptop computer. He was researching his case, and he knew about antibodies to Ebola.

  Standing close to the crack in the window, Hensley quickly summarized nineteen possible options for him to consider. This was swift technical talk between a scientist and a doctor who needed a drug to save the life of a colleague and himself. Hensley had brought with her a spreadsheet, and she went through the list. She had done lab research toward the development of most of the compounds, and most of them had never been tested in humans. In January, Tekmira Pharmaceuticals had begun testing a drug, TKM-Ebola, in humans, evaluating it for safety. It had shown decent results in monkeys, but the drug had been put on partial hold while the company collected more information for the Food and Drug Administration. There was a drug called T-705, which had been tested in Japan, in humans, against influenza virus; the drug might have some effect on Ebola. Hensley told Brantly that she had participated in a study of a drug called rNAPc2, an anticoagulant made by a company called Nuvelo that had saved one of three monkeys it was tested on. There was the vaccine called VSV-ZEBOV, which Hensley had also worked on. Another vaccine known as an adenovirus plus IFN-Alpha. A drug called PMOPlusR. And there were more drugs to consider, as well.

  Brantly focused his attention on ZMapp. The drug had saved monkeys. But, still, he didn’t know what to do. When Hensley finished her review of the possibilities, Brantly’s voice came through the window: “What would you do, Lisa?”

  She couldn’t tell him what to do. She had worked on many of the compounds, and the drugs were unlicensed and untested. She was bound by law and ethics not to advise anybody to take any drug under those circumstances. “These are all very personal decisions,” she said.

  Then she told him that she had been exposed to Ebola, sixteen years earlier. At the age of twenty-six, working in a space suit with liquids full of Ebola particles, she had cut her finger with scissors, which had gone through two layers of gloves. The only experimental treatment at that time was a horse serum made by the Russians, which could kill her, and she had decided not to use it unless she was certain that she had contracted Ebola. On the night of the accident, after a meeting to analyze what had happened, she was sent home to her apartment. She called her parents and told them that she might come down with Ebola and that they would have to collect her belongings and take her cat home with them.*

  Brantly listen
ed, and said that of the drugs available he probably would choose ZMapp for himself, based on the data, even though it had never been tested on humans. Hensley offered to donate blood if he had hemorrhages.

  Lance Plyler then drove her across the compound to the house of “Nancy Johnson,” who was a woman named Nancy Writebol. Her house was near the beach. She had been working in the disinfection line outside the Ebola ward, spraying people with bleach as they exited and helping them remove their gear. When Hensley and Plyler arrived, Nancy’s husband, David, who was considerably older than Nancy, was getting ready to enter the house to help his wife. The house had become a red zone. As he got himself dressed in PPE, Hensley saw that he was fumbling with his equipment. He clearly wasn’t a medical person.

  He fitted on his mask and goggles, and went inside, and Hensley stepped up to a window to observe. The window was wide open and had a screen in it. Nancy was lying in a bed by the window, and a ceiling fan was turning, blowing air around her to cool her skin. She had a fever and was extremely ill: Hensley could see that she was dying, and that David Writebol knew it.

  Nancy wanted to use the bathroom. David helped her out of bed. She had difficulty standing. Then the couple walked slowly toward the bathroom.

  Hensley began to feel uncomfortable watching this. She turned her back, to give them privacy, and found herself looking up at the sky. The rain had cleared off, the clouds had vanished, and the sky was a black dome glittering with stars. The Milky Way stretched across the top of the sky in a band of haze embedded with blue-white and golden stars and rifts of dark smoke. Hensley had a moment to think, and she began assessing her life and its meaning.

  She thought about what she had just seen. As David Writebol was putting on PPE and preparing to go into the house to help Nancy, he was clearly nervous, frazzled, uneasy, but when he walked into that room all that mattered to him was Nancy.