by Reid Wilson
“We were concerned that cases that were testing negative for Lassa fever … are presenting as acute viral illnesses,” Khan told an interviewer of those early days. “What else could it be?”2
The Kenema Government Hospital’s Lassa ward had been established first in the 1970s. In 2005, just after Khan took over, it had helped develop the first diagnostic test for Lassa, and in 2014 it had won a major grant from the U.S. Navy to build a new ward, one with forty-four beds and critical modern features like air conditioning, to protect doctors at risk of overheating in sweltering space suits; tiled floor; and a modern drainage system. (Construction on the new ward paused during the outbreak as workers fled the disease, and the hospital.)3 The Lassa ward was staffed by nurses who had suffered from, but survived, the hemorrhagic fever, which made them immune to catching the disease a second time.
But Kenema remained far below the standards of a traditional Western hospital. It was, in Schoepp’s description, little more than a series of shacks, full of outdated medical equipment. Its roof was made of corrugated tin, its beds resembling flat beach chairs with slats, through which diarrhea and blood would ooze. Twisted wires held the metal walls together. In June, one of the walls collapsed; Khan ordered it rebuilt, with lower ceilings so it would be more stable.4 When nurses ran low on supplies, they would wash out pairs of latex gloves, only meant to be used once, and leave them in the hot African sun to dry.
As possible Ebola cases mounted, even the relatively well-prepared hospital was quickly overwhelmed. Patients would arrive in a big white canvas tent, known as the annex, to have their blood drawn and wait for their diagnosis. Confirmed cases would be taken to Ward A, which could accommodate about thirty patients in its eight rooms. As those beds filled, patients were taken to a hastily constructed Ward B. Technicians in personal protection equipment would remove dead bodies to a makeshift morgue, a small shed behind Ward A, where they were stacked like cords of wood. The pile grew so high in June that some would tumble off the top, obstructing walkways.
Soon Garry’s team of investigators found themselves working closer and closer to home, tracking contacts in Kenema itself. The teams counted every case they could, even those for whom they did not have space in the hospital. They traced contacts. They watched their own community get sick. They spent their days off, Garry recalled quietly a year later, “going to funerals.”
But Khan made a point of showing compassion when he could. On the rare occasion that a patient was able to leave the hospital after fighting off the disease, Khan would hug them, in public, to show that survival was possible.
“These are people I embrace myself on the day of discharge, because don’t forget the stigma about Ebola,” he told a local newspaper.5 “With some people, you have to give them certificates so that by the time they return to their villages people will understand that they are no more suffering from the disease and they are free to interact with the population.… I embrace them to, of course, tell the public that yes, this is the situation.”
Those optimistic moments were few, and rapidly becoming fewer. Khan worked ten-hour days, then twelve, then seemingly nonstop, caring for patients. His office, where he dressed in his own personal protection gear, was nothing more than a trailer positioned next to the isolation wards. Its mirror, in which he checked for cuts or tears, was “the policeman,” he said—his own way to ease his mind before entering the hot zone. Still, he was aware of the risks he was taking. He told his interviewer:
Of course, I am afraid for my life, because I must say I cherish my life. And if you are afraid of it you will take the maximum precautions, which I am doing. If you neglect … then you will ignore most of these personal protective equipment [PPE] and you wouldn’t do things correctly. So having that in the back of my mind I make sure whenever I am going into the isolation unit I make sure that I am in full PPE.
Khan’s family begged him to leave, like so many other doctors had. Once again, Khan said he would stay.
“If I refuse to treat [my patients], who would treat me?” he asked his sister.6
He repeatedly demanded that his nurses, so many of whom were like family to him, take the same precautions—dress in head-to-toe personal protection equipment, wash repeatedly with chlorine solution. When the outbreak moved into Sierra Leone, Robert Garry arrived with nine trunks, filled until bulging with gloves, masks, and Tyvek suits, enough gear for nine hundred clothing changes.
Soon, those clothing changes began to run out. By early July, Khan spent hours a day e-mailing colleagues, former classmates, and every American official he could remember, begging for supplies. They needed chlorine, gloves, goggles, protective suits, and salts to fight the dehydration that ultimately killed so many Ebola patients. He asked for 3,000 adult-sized body bags, and 2,000 small enough for children.7
But not every nurse took those precautions seriously. Some wore shoes from home into the isolation wards, then sprayed them down with hoses before going home. Khan himself was seen lifting his goggles inside the isolation ward to clear condensation that formed on the lenses.
There were other holes in security, too: When the chief of a local tribe arrived at a private ward on the hospital’s campus, he infected the nurse who treated him. That nurse was pregnant; when she fell ill, four other nurses from Khan’s ward helped induce labor to deliver her stillborn baby. It was a risky procedure, both for the woman and her nurse colleagues, but they knew it was the only chance they had to save her life. Blood was everywhere.8 All four nurses who tended to the young woman got sick themselves.
One of those nurses was Mbalu Fonnie, the hospital’s head nurse. Mbalu was a pillar in her community; many had mourned alongside her the year before when her husband, who headed Kenema Government Hospital’s outreach team, had died of liver cancer. She was held in such high regard, with such a close relationship to the director, that Khan called her Mom.
By the time she was infected, Kenema was overrun, with more than seventy patients in treatment or isolation. Instead of placing her in the ward with those patients, Khan broke protocol to place her in a private room in the observation wing. It hardly mattered—virtually every sample taken from a patient in the observation wing was coming back positive anyway. Khan was working almost alone; the other doctors at the hospital had all fled, or died.
Security at the hospital was nonexistent. It was left unguarded, and some patients, either desperate to save themselves or delirious from the disease raging inside them, simply got up and left. When Fonnie fell ill, a vigil held in her honor outside the hospital rippled, then roared with rumors that she had died. The crowd became angry and threatened to storm the hospital. Though the police were summoned, there wasn’t much they could do. The crowd was stilled only by Khan himself, alone, clearly near the edge of his capacity.
“My nurses are dead,” Khan told the crowd. “And I don’t know if I’m already infected or not.”9
A few days later, Khan and his closest friend, a nurse named Alex Moigboi, walked out of Ward A, after hours in the dripping heat. They undressed, raised their arms to be sprayed by chlorine solution. Moigboi turned to Khan to confess: He wasn’t feeling well. He had treated the young pregnant nurse a few weeks earlier. Without thinking, out of pure instinct, Khan reached for Alex’s eyes for a quick look, making skin-to-skin contact.10
Moigboi’s test came back positive. On July 19, the day Moigboi died, Khan returned home feeling more exhausted than usual. He told his assistant he was worried. At a staff meeting at the hospital that day, several people noticed he appeared unwell. The fever came back that afternoon, and so did a headache. On Sunday, July 20, Khan woke up too sick to work. He managed to get himself to the hospital, where his own blood was tested. The tests came back negative. The same day, Fonnie succumbed.
On Tuesday, Khan’s condition had not improved. Technicians drew more blood and ran a second test. Khan tried to rest at home, but hours later the district medical officer showed up—these tests had come back po
sitive. Khan’s blood was filling with the Ebola virus.
Khan and the medical officer considered their options, but they both decided the least palatable would be to check Khan in to his own hospital. Morale was already low, and watching their ace doctor, their national hero, fight for his life could destroy what little of it was left. The better option was to transfer Khan to the Médecins Sans Frontières (MSF) Ebola treatment center in Kailahun, seventy-five miles away. Khan climbed into an ambulance for a grueling, bumpy five-hour ride through a torrential monsoon.
The MSF facility in Kailahun was more modern than the Kenema Government Hospital. It consisted of six white tents, each with eight beds known as “cholera cots,” with holes for bodily fluids to slip through. There, doctors gave him medication for pain, antibiotics to fight the disease, and salts to help his diarrhea-racked body rehydrate. They did not insert an IV, something MSF treatment centers avoided.
Khan’s illness set off alarms in Freetown. Sierra Leone’s national hero, a very public face of the outbreak, needed help. Government officials sent desperate e-mails to an army of experts from across the globe, in search of any kind of cure, no matter how experimental. As it happened, one possible solution, never before tried on a human, was sitting in a freezer in Kailahun.
The serum was called ZMapp, an experimental drug that had proved effective in chimps. It was made of antibodies grown in tobacco plants in Kentucky, fashioned into a compound by a small pharmaceutical company in San Diego. The three doses that made up a full treatment course were left behind by a Canadian researcher who wanted to test whether the drug could survive in the harsh tropical heat. Now, officials from the World Health Organization (WHO), the Centers for Disease Control and Prevention, Canada’s Public Health Agency, USAMRIID, and MSF spent hours on the phone debating whether they could test an experimental drug—one that had never even entered the human bloodstream—on such an important patient. Garry and his colleagues, who had worked for so long alongside Khan, called everyone they could think of, demanding that Khan be given the drug. If anyone deserved it, they said, he did.
Khan was told that the debate over whether he would get the drug was happening over phone lines in Washington, Atlanta, Ottawa, and Geneva. No one asked for Khan’s opinion. The Americans and Canadians argued it was worth the risk, but the decision was ultimately left to WHO and MSF. Their decision took into account the worst-case scenario: in an atmosphere in which so many Africans already distrusted Westerners in space suits, if they gave Khan the drug and he died, they could expect to confront a riot.
On July 25, three days after arriving in Kailahun, Khan was told he would not be getting the drug.
In his first three days in treatment, Khan’s condition appeared stable. He moved with ease, sitting outdoors at the Kailahun clinic, speaking with visitors through a protective mesh barrier. He asked his assistant to bring a cell phone charger so he could keep in touch with friends, family, and his clinic back in Kenema.
But as the virus grew within him, Khan became weak. On the fifth day, Khan had to be helped outside; he could not sit up on his own. Another infected nurse from Kenema, arriving for treatment in Kailahun six days after Khan, found the doctor frail, but able to sit up in bed.
After medical officials decided against giving him ZMapp, Sierra Leone’s Ministry of Health played its last card, desperately trying to find a Western hospital that could treat Khan. The government hired International SOS, a French company with a jet capable of keeping a patient in isolation during flight, to evacuate Khan to another country. Miatta Kargbo, the nation’s minister of health, burned up the phone lines, calling colleagues in Switzerland, the United States, Germany, and other countries: Would you take Khan, she asked, and save his life? One by one, the Western governments declined—they did not want to take a confirmed Ebola patient, and several didn’t think Khan would survive the trip.
After days of haggling, one government agreed to take Khan.11 But MSF doctors said Khan’s white blood cell count was too low, making it unsafe for him to travel. By July 29, that critical count rose, though he could no longer stand on his own. Trembling with weakness brought on by near constant diarrhea, Khan asked nurses to take him outside one more time.
It was there, in the sun of the afternoon, propped on a pillow, where the hero of Kenema died. The minister of health personally called his family to deliver the news.
Khan’s death hit Garry, and the colleagues who had worked alongside him for so long, hard. Somehow, perhaps to get them to back off, they had been told that Khan would get the ZMapp treatment. When he died, Garry said in an interview, his eyes growing moist, “we just assumed it didn’t work.” Garry learned Khan had not gotten the drug from a report in the New York Times.
“They lied to us,” Garry said.
Sheik Umar Khan, thirty-nine years old, came home to Kenema a few days later. Five hundred people attended his solemn funeral behind the Kenema hospital where he spent his life. No others are buried near him; the only item indicating his final resting place is a slab of tiled concrete.
The new Lassa research center, funded by the U.S. Navy, bears Khan’s name.
SEVEN
Lagos
THE GLOBAL EPIDEMIOLOGY COMMUNITY is relatively small and tight-knit. Even those who see each other as rivals are cordial and close; where other academics blow disagreements over theory out of proportion, those who spend their time in the field fighting ghastly diseases cannot help but see the good in their colleagues. The death of Sheik Umar Khan, his illness apparently so mismanaged by global health authorities, enraged those who had known Khan—and, importantly, those who had been urging the World Health Organization (WHO) to stop dragging its feet and declare an emergency months earlier.
But while so many in the medical community were pulling for Khan, another potential disaster, a cataclysm that would make the outbreak in Sierra Leone, Guinea, and Liberia look tiny by comparison, was threatening about a thousand miles away. On July 20, the same day Khan felt sick enough to ask colleagues to draw his blood, Patrick Sawyer arrived in Lagos, Nigeria.
Lagos is Africa’s largest city, the commercial capital of Africa’s largest country. It is home to more than 20 million people, some of whom live in slums with a population density of 50,000 people per square kilometer.1 Its population is highly mobile, both internally and externally. It is an international city in the way Freetown, Conakry, or Monrovia are not; Lagos’s Murtala Muhammed International Airport serves international destinations from London to Johannesburg, Istanbul to Madrid to Nairobi—and Atlanta, New York, and Houston. Nigeria’s oil and mining industries bring international businessmen from across the globe to Lagos, where they mingle with those who live in crowded slums. In other words, Lagos is not only the perfect petri dish for a virus that spreads from person to person through physical contact, it could also be the launching pad the Ebola virus needed to go from local epidemic to global pandemic.
“The last thing anyone in the world wants to hear is the two words ‘Ebola’ and ‘Lagos’ in the same sentence,” Jeffrey Hawkins, the U.S. consul general in Nigeria, said in 2014.2
All Lagos needed to become Ebola’s launching pad was an index case. And to many in Monrovia’s airport on the morning of July 20, Patrick Sawyer, a Liberian American lawyer scheduled to represent Liberia’s Ministry of Finance at a conference, looked suspiciously like that index case. Even before he boarded the plane, he looked obviously ill; footage from a surveillance camera showed him lying facedown in the terminal’s waiting area. He refused to shake an immigration officer’s hand, a sign he knew he was sick. On the flight to Lagos, he vomited. He vomited again in a private car on the way to a hospital, after Nigerian immigration officials diverted him at the airport in Lagos. Sawyer insisted he had malaria, or something similar; after all, he had not come into contact with any Ebola patients back home in Liberia. Malaria is not transmitted person-to-person, so several nurses did not bother to take precautions when checking him in.
At the hospital, however, Dr. Stella Ameyo Adadevoh suspected her patient was lying. After twenty-one years on staff, the veteran physician knew what she was seeing, and she knew Sawyer had something far worse than malaria.
She was right. Weeks before he traveled, Sawyer had cared for his sister, Princess Nyuennyue, who had arrived with her husband and her brother at Saint Joseph’s Catholic Hospital in Monrovia in early July; her husband told doctors at Saint Joseph’s that she was suffering a miscarriage. Sawyer had paid $500 to get his sister into a private room; while the medical staff worried the woman might have Ebola, Sawyer helped her change clothes.3
Princess Nyuennyue died on July 7 or 8. Sawyer, who worked as a consultant to the mining company ArcelorMittal, told his employers the next day that he had had contact with his sister. The company reported the contact to the Ministry of Health, which ordered Sawyer not to travel until he was no longer an infection risk.
Saint Joseph’s itself suffered drastically. Brother Patrick Nshamdze, the hospital administrator, died August 7, buried in a mass grave that included fifty-two other victims. Seven other staff members who treated Brother Patrick also fell sick.4 (One was Father Miguel Pajares, a seventy-five-year-old Spanish priest. He was evacuated to Spain, where he received a full course of ZMapp. The experimental drug did not work.) Weeks after its first Ebola case, Saint Joseph’s, the oldest hospital in Liberia, shut down.
Before the twenty-one-day incubation period was up, Sawyer began to feel feverish. He was hospitalized on July 17, though he left the hospital, against his doctor’s orders, a few days later. By July 20, he showed up at the airport for the flight, which connected in Togo, determined to deliver a lecture at the economic conference he was to attend in the Nigerian city of Calabar.5 It is not clear why Sawyer decided to defy his travel ban. His boss at first acknowledged approving Sawyer’s travel, then later reversed himself and denied issuing permission.
