by Reid Wilson
Brantly was just thirty-three years old when Ebola came to Liberia. A deeply religious man, he had studied at Abilene Christian University in Texas, where he hoped to become a missionary. During his college years, he went on a mission trip providing care to poor children in Central America; it was a life-changing experience, one that convinced him that medical missionary work was the channel through which he would serve God. He earned his medical degree from Indiana University in 2009, then trained at John Peter Smith Hospital in Fort Worth, Texas, where he worked in a program for doctors who would practice in rural communities or in the developing world.
Only months after finishing his residency, Brantly, his wife Amber, and their two children had moved to Liberia, in October 2013, volunteering with Samaritan’s Purse, an organization founded by the evangelist Franklin Graham. Their small home, covered by a thin tin roof, faced the Atlantic Ocean. He quickly built a reputation at the ELWA 2 facility as a man of deep compassion: When it became clear that any of the sick patients wouldn’t survive, Brantly, clad in head-to-toe protective gear, would hold their hands, pray with them and sing to them.1
At the ELWA 2 hospital, Brantly met Nancy Writebol and her husband David, volunteers for another Christian ministry, Serving in Mission, the parent nonprofit that operated the ELWA hospital. David’s job was to keep the facility running, to keep the lights on and the generators pumping. Nancy was a clinical nurse associate, given the critical tasks of ensuring that doctors and nurses were properly suited in personal protection equipment before entering the isolation wards, then spraying them down with chlorine when they came out.
It was a relatively low-risk, though crucial, assignment; a line of tape on the floor of the shower area separated Writebol, dressed in gloves and a disposable apron, from doctors and nurses in full-body suits. Writebol would also take the temperatures of family members of infected patients, though none of them showed any signs of infection.
On July 22, her fifty-ninth birthday, Nancy Writebol came down with a fever, a symptom she knew well. A few months before, Writebol had contracted malaria, and now she thought the disease had returned. She asked a Serving in Mission doctor for a malaria test, which came back positive. Writebol returned to the small home she shared with David, where she had malaria drugs in the bathroom. All she needed, she thought, was some medicine and a few days’ rest.
But her symptoms kept getting worse. The fever didn’t break, and soon she developed a dull, intensifying headache. On Saturday, the same doctor who had given Writebol her malaria test stopped by their house. The doctor didn’t want to frighten anyone: “We’re just going to do the Ebola test, to relieve everyone,” she told Writebol. The doctor and David left for an all-staff meeting at the hospital, taking her blood sample with them. Writebol lay down for a nap.
A few hours later, once the samples had made their way to Schoepp’s lab, Lance Plyler, Brantly’s boss, got a text message from Schoepp’s team: “I am very sad to inform you that Tamba Snell is positive,” the message read. A short time later, Writebol’s sample—labeled Nancy Johnson—came back positive, too.2
David returned to their house. He stood outside the door: “Nancy, I have something to tell you,” he said. “Nancy, Kent has Ebola. And so do you.”3
The doctors who had accompanied David back to his home, to give his wife such terrible news, were beside themselves. “We are so sorry, Nancy. We are so sorry,” she later recalled them repeating, over and over.
Writebol was painfully aware of her odds. In the weeks since the ELWA facility had opened, she had watched forty patients enter the Ebola ward—the twenty beds for suspected cases quickly became twenty more beds for confirmed cases, and even then they had to turn potential cases away. Just one of those forty patients had survived. When the first two patients arrived on June 11, one, an older man, had not even survived the ambulance ride.4
In the weeks that followed, Writebol went over her time at the ELWA facility, trying to recall a moment when she might have come into contact with someone who was infected. Another technician who sprayed down doctors and nurses coming out of the isolation wards, a Liberian, had been infected a few days earlier in his community; he had come to work while showing early symptoms, but even then Writebol could not recall physically touching her colleague. She never figured out the moment at which she could have contracted the virus.
It mattered less how they were infected than how they would be treated. Plyler began making every phone call he could—to the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Canada’s Public Health Agency. He learned about more than a dozen possible treatments, with names like T705, rNAPc2, TKM-Ebola, and ZMapp. None had been tested on humans, though ZMapp had worked to cure monkeys infected with Ebola.
Plyler called Larry Zeitlin, the president of Mapp Pharmaceuticals, to beg for a dose. The only treatment course that was anywhere near the ELWA facility, though, was in the freezer in Kailahun, Sierra Leone, where at the same time Sheik Umar Khan lay dying. Brantly and Writebol both said they would opt for that drug, if it was available. Plyler and Zeitlin made contact with Gary Kobinger, of Canada’s Public Health Agency, to try to get the drug to the nearest airstrip, across the border in Foya, Liberia.5
The U.S. embassy in Monrovia sent Lisa Hensley, a microbiologist at USAMRIID who had spent her career looking for possible drugs to treat hemorrhagic fevers like Ebola, to Foya by helicopter to pick up the sample. She was accompanied by a U.S. marine—just a precaution, they were told. After flying through thick fog and pelting rain, they discovered that the doses of ZMapp had already left aboard a flight chartered by Samaritan’s Purse. The helo heaved back into the sky to return them to Monrovia.6
The three-dose course of ZMapp arrived at the ELWA 2 hospital in a Styrofoam cooler. Kobinger and others had been clear with Plyler: there is only enough medicine to treat one patient, they told him. The drug acts like a boxer fighting a particularly resolute opponent. One dose, or one punch, would knock the disease down, but it required two more punches to knock the disease out. Whatever he did, Plyler was not to split the doses between both patients.7
Plyler drove to Brantly’s small home, where he could speak to him through the window. The young doctor was doing better than expected, hovering in stable condition. He expected to be evacuated to the United States within just a few days. Together, they decided Writebol should get the treatment. Brantly called Writebol and urged her to take the drug.
Plyler jumped back into the car, drove the short distance to Writebol’s home, and handed the drug to Dr. Debbie Eisenhunt, one of ten doctors and nurses attending to the two Americans around the clock. Eisenhunt placed the first dose under Writebol’s arm, where it would thaw slowly; too fast and the serum could be destabilized.
Just hours later, on July 31, Brantly began to spiral. He looked visibly worse, sweating, groaning in pain. Plyler called Brantly’s wife, Amber, and Franklin Graham, to let them know. And he began to consider doing exactly what he had been told not to do—splitting the doses. Plyler unpacked the second dose and began to thaw it. Plyler closed his eyes and bowed his head: “God,” he prayed, “he cannot die.”
Plyler returned once again to Writebol’s house, where Eisenhunt retrieved the now-thawed first dose from under Writebol’s arm. They disinfected it, then wrapped it in a plastic bag, where it rode next to Plyler on the short trip back to Brantly’s home. There, he handed the vial to another physician, Dr. Linda Mobula, who inserted the drug into an IV bag dripping into Brantly’s arm. Plyler sat vigil outside Brantly’s home as the first drops of ZMapp filtered down into Brantly’s vein.8
Within half an hour, as the drug coursed through Brantly’s bloodstream, he began to shake, a tremor at first, then uncontrollably. It was the first hint that ZMapp was having an effect. After an hour of shaking, Brantly seemed to calm. Miraculously, it seemed, his fever broke, his temperature began to return to normal and his breathing, once laborious, steadied. Even the
rash on Brantly’s chest seemed to fade. Doctors hooked up a new bag, this one a blood transfusion from a fourteen-year-old boy who had survived Ebola, and whose blood would carry antibodies that would give Brantly’s immune system another weapon against the disease.
The following morning, Brantly stood up and walked to the bathroom. A day before, he hadn’t been strong enough to stand.9
Writebol was not as lucky. Her first dose, the second in the course, administered beginning August 1, did not show the same instant effects it had on Brantly. In fact, she began to develop an itch on her hands, a possible sign of an allergic reaction. Her doctors dialed back the amount of serum dripping into her veins, which seemed to ease the discomfort.10 She, too, got blood transfusions, though none with Ebola antibodies—none of the Ebola survivors matched her blood type.
Back in the United States, the White House and the State Department scrambled to find a way to get the two Americans home. They identified one company, called Phoenix Air Group, that could do the job. The company, based in Cartersville, Georgia, had a single plane that could fly a patient at Biosecurity Level 4, the most secure environment. The “air ambulance” held a sealed room behind the cockpit, which was kept at lower air pressure than the rest of the plane. This ensured that any leaks would suck air into the compartment, rather than pushing air into the cockpit.
But even with the proper equipment to transport the two patients, there were problems. The air ambulance had taken off for Liberia on July 30, the day before Brantly received his first dose of ZMapp. It had to turn back because of a pressurization problem.11
Finally, on the morning of August 2, Brantly walked onto the plane under his own power. It lifted off, headed back to Atlanta. After it landed at about 11:20 a.m. local time, news helicopters captured video of a man in full personal protection equipment climbing out of an ambulance and walking slowly toward the open doors of Emory University Hospital, where an isolation ward waited. He was helped by another person in full protective gear. Kent Brantly was home.
Now, it was Writebol’s turn. The Phoenix air ambulance lifted off once again, bound back across the Atlantic.
But the second American was struggling. She had received two doses of the three-dose course, though she hadn’t experienced the same rebound as Brantly. Doctors had trouble finding a vein to keep her IV in; they eventually put an IV directly into the bone, which caused her terrible pain.12
Just hours before she would take off for Atlanta, Writebol made a point of asking for her favorite Liberian dish, a potato soup. She wasn’t sure she would ever have the chance to try it again; she didn’t think she could survive the ten-hour flight stateside.13 Dressed in full protection equipment, she was loaded onto a luggage conveyor belt to be placed in the level-4 biocontainment suite on the plane. One of her doctors put his hands on her mask and brought his face close: “Nancy,” he told her, “we’re taking you home.”
On August 4, Writebol arrived at Emory too. Brantly could see her through the window of their adjoining isolation units. He tried to wave, but she was too delirious to see him.
But with constant supervision in a world-class medical facility, both patients quickly improved. A new dose of ZMapp had arrived from Kentucky BioProcessing, the facility that made the experimental drug using tobacco plants, and both Brantly and Writebol completed their treatment courses. They discovered that small encouragements mattered. The day a doctor told her she had turned a corner, Writebol willed herself, for the first time in a week, to stand up, go to the bathroom and take a shower. Two weeks after entering Emory’s hospital, Kent Brantly walked out with a clean bill of health.
The happy ending to the stories of Kent Brantly and Nancy Writebol served as a rare positive moment, and a dire warning, to the global health community. On one hand, there was now evidence that the Ebola virus could be beaten. On the other, their illnesses had virtually shut down ELWA 2, one of the only hospitals in a city of a million residents where a highly contagious disease was only beginning to spread. Three other Liberian health-care workers at ELWA 2, including Writebol’s colleague, had also fallen ill. Two had died. Other NGOs saw the collapse as a particularly scary reminder of the ever-present danger. Two volunteers got sick at the first NGO other than Médecins Sans Frontières that tried to open an Ebola ward
In the United States, the sick Americans served as a catalyst for top disaster response experts, who began to realize the scale of the outbreak, and the warnings they had been hearing from Frieden, Fauci, and others.
“For us, the fact that Monrovia was now left without a net was much more concerning [than the two Americans falling ill],” said Jeremy Konyndyk, the head of the United States Agency for International Development (USAID) Office of Foreign Disaster Assistance. “From a containment of the disease perspective, what really started the alarm bells ringing was not that two Americans were sick, but that the one treatment option in Monrovia is collapsing, and there was nowhere for patients to go.”
The fact that Writebol and Brantly had survived, and that Dr. Sheik Umar Khan had not, set off another debate, one that put the World Health Organization (WHO) on the spot. WHO had been cautious about using the experimental ZMapp on a human without proper trials.
“Using an experimental vaccine on human beings in the middle of an outbreak in this case would not be ethical, feasible or wise,” one WHO official had told Science Magazine.14 But Writebol and Brantly were alive, and Khan was dead.
On August 6, WHO changed its stance. It would convene a panel of experts to consider the ethical ramifications of an experimental vaccine or treatment.
“The recent treatment of two health workers from Samaritan’s Purse with experimental medicine has raised questions about whether medicine that has never been tested and shown to be safe in people should be used in the outbreak and, given the extremely limited amount of medicine available, if it is used, who should receive it,” the agency wrote.15
But experimental drugs are just that, experimental. And the Centers for Disease Control and Prevention wanted to temper expectations as much as they could.
“The plain fact is that we don’t know whether [ZMapp] is helpful, harmful, or doesn’t have any impact,” CDC director Tom Frieden told a congressional committee on August 7. “And we’re unlikely to know from two or a handful of patients whether it works.”16
The message Frieden was sending was clear: The Ebola outbreak would not be stopped by a miracle drug, one that was both unproven and unlikely to be produced in mass quantities. The world needed to do more—and given that the WHO had proved so inept at accomplishing the job, the United States needed to take on a bigger role, maybe even the lead.
It was a message that would be delivered over the next month, repeatedly, as case counts mounted. By August 8, 2014, more than 1,700 total cases had been reported across Guinea, Liberia, and Sierra Leone. More than 950 people had already died. And the curve was beginning to bend upward.
NINE
A Call for Help
IN EARLY AUGUST, Liberian president Ellen Johnson Sirleaf called her chief ally on Capitol Hill, Senator Chris Coons, the chairman of the U.S. Senate Foreign Relations Subcommittee on African Affairs. Coons admired Sirleaf, a bipartisan cause célèbre in Washington at a time when there had not been many success stories in Africa. When Sirleaf was elected president in 2005 as the unity candidate capable of healing the deep wounds left over from the country’s second civil war, First Lady Laura Bush and Secretary of State Condoleezza Rice had attended her inauguration. Sirleaf had given a joint address to Congress, a rare honor for a foreign leader; George W. Bush had awarded her the Presidential Medal of Freedom, the highest civilian award an American president can bestow; and Barack Obama welcomed her to the Oval Office in 2010, crediting her “heroism and courage” in helping Liberia heal. She shared the Nobel Peace Prize in 2010, an award she won for her work to promote women’s rights (though the timing of that award, coming just days before Sirleaf won a second term, was not with
out controversy).
Coons, a freshman Democrat from Delaware, knew more about the desperate poverty of Africa than most of his colleagues. He had served as a relief worker in Kenya and written a book on South Africa during apartheid. And he knew Sirleaf well. He had attended her second inauguration, after she won reelection with 90 percent of the vote (the opposition candidate had boycotted the election after the controversy over the Nobel Peace Prize). The two politicians, one a brightly dressed African woman in her seventies who had seen the worst of civil war, the other a low-key backbench senator with a graduate degree from Yale Divinity School, formed an unlikely bond; Coons thought Sirleaf was tough and resolute.
But now Coons heard a desperation in Sirleaf’s voice. Her country, she told him, was dissolving around her, laid prostrate by a virus the public health infrastructure had no ability to defeat. The World Health Organization (WHO) was so miserably behind the curve that the number of Ebola cases was beginning to skyrocket, both in the remote rural counties up north and in crowded and impoverished Monrovia itself. Help, she said, was nowhere on the horizon.
“Everything was shutting down. They were feeling a sense of abandonment by the world. Airlines were stopping [flights], cargo ships were no longer coming,” Coons recalled later. “They increasingly felt isolated.”
Coons promised help. He thought he had grasped the seriousness of the situation, but when Sirleaf made a specific request for funding, Coons realized the true magnitude of the burden Liberia faced: Sirleaf’s country needed help building a crematorium to dispose of dead bodies that would otherwise infect someone new. They simply did not have the space, or the time, to bury the dead.
Over the scratchy transatlantic connection, Sirleaf and Coons prayed together.
