by Reid Wilson
The Army took seriously the concerns that Dempsey, chairman of the Joint Chiefs of Staff, had laid out: Costello and his team were only there to build facilities, not to treat patients; Costello himself never saw anyone infected with the disease they were fighting. While more than a few soldiers came down with minor ailments, from headaches to high fevers to regular aches and pains, not a single American solider contracted the Ebola virus.
Around them, it was a different story. By the time Costello landed in Monrovia on October 16, 8,973 people had been infected across the three West African nations, and 4,484 victims of the Ebola virus lay dead.
THIRTEEN
Dallas
FOR YEARS, THOMAS ERIC DUNCAN languished, alone, thousands of miles from his family, the woman he loved, and the son he hadn’t seen grow up.
Duncan had been one of hundreds of thousands of civilians who fled Liberia’s deadly civil war in the 1990s, forced out of his own home and into a squalid refugee camp across the border in Ivory Coast. He had tried to start over, living with his brother in a tent. The two young men befriended the woman who lived in the tent next door, Louise Troh; Duncan fell in love. Amid the poverty of years in the camp, Troh and Duncan had a son, Karsiah, in 1995.
Everyone in the camp longed for a visa to the United States, a veritable golden ticket that held the promise of a new life on American shores, far away from the violence and poverty of the home they no longer knew. Troh and Karsiah won the lottery in the late 1990s; Duncan, who had never married his partner, was left behind. He spent another decade and a half in the camp, where he learned French, Ivory Coast’s official language.
Finally, in 2013, Duncan, still yearning for a ticket to America, felt it was safe enough to return home to Liberia. He moved into an apartment and got a job as a driver for a FedEx contractor. Louise had moved to the Dallas area, where Karsiah had grown up as a promising student, a high school quarterback who won admission to a college in San Antonio.
Then, Duncan’s luck seemed to change. One day the phone rang at the home of Wilfred Smallwood, the brother who had shared Duncan’s tent in the refugee camp and who now lived in Phoenix: “I got my visa! I got my visa!” Duncan shouted, ecstatic.1 His life seemed to be moving again; he and Troh would be married when he arrived, his son thrilled with anticipation at the prospect of seeing his father once again. Troh helped him book his plane ticket, from Monrovia through Brussels, then to Washington and on to Dallas.
In the days before his plane left, a young woman named Marthalene Williams needed his help. Williams, the daughter of Duncan’s landlord, was pregnant. She was also sick. Duncan, the landlord, and the landlord’s son piled into a taxi with the young woman, bound for Monrovia’s main hospital, and the nation’s largest Ebola ward. Duncan later said he believed she was miscarrying; he didn’t know she had the virus that was raging through his country.2
But the hospital had no room. Like so many others who were suffering, Williams was turned away. They got back into the taxi, and Duncan carried her into her own apartment. Williams, her brother, and her father would all be dead within a few days.
On September 19, Duncan arrived at Monrovia’s airport. Asked whether he had been in contact with anyone who had Ebola, Duncan said no. Whether his omission of the young pregnant woman was a lie or whether he truly did not know she was sick remains unclear. Either way, Duncan showed no signs of any disease; he boarded the airplane. By the next day, after layovers in two of the world’s busiest airports, he arrived in Dallas on United Airlines flight 822.3
Troh was ecstatic. She drove Duncan home to their apartment in Vickery Meadows, a melting pot of a neighborhood in Dallas, a magnet for new arrivals from South and Central America, from sub-Saharan Africa, a mini United Nations deep in the heart of Texas.
Five days after he arrived, Duncan began to feel aches in his joints and shooting pains in his abdomen. He developed a fever. That night, at 10:00 p.m., Duncan drove the few miles to Texas Health Presbyterian Hospital. A nurse took his temperature—103 degrees, well above normal—and asked whether he had traveled recently.
Texas Presbyterian was one of the dozens of hospitals across the country that had made initial plans in the unlikely case an Ebola patient walked through its doors. Just a week before Duncan had arrived, the hospital had run drills to prepare for a patient who needed to be isolated.4 The Centers for Disease Control and Prevention (CDC) had issued an advisory to American hospitals on August 1, urging those facilities to be alert for anyone complaining of fever, stomach pain, joint aches, vomiting, or diarrhea. The CDC issued a follow-up alert on September 4.
Duncan told the nurse he had just arrived from Africa, though he did not specify that he had been in West Africa. But the staff seemed to miss the message; a doctor prescribed Duncan antibiotics and sent him home to recover.
Over the next three days, Duncan’s condition worsened. By September 28, he could no longer get out of bed, so weakened by the constant tremors and emissions that taxed his body. That day, he returned to the hospital’s emergency room in an ambulance.
By now, the nurses suspected they might be dealing with something never before seen in an American hospital. Sidia Rose, the nurse who first interviewed Duncan in the emergency room, wearing some protective gear, asked her patient again about his time in Africa, and whether he had come into contact with anyone who might have been sick. Duncan once again said no. The doctors treating him huddled: Duncan might have malaria, they guessed, or gastroenteritis, or a particularly nasty flu. Or, one speculated, he might have Ebola. Duncan lay in the emergency room for at least three hours before his doctors put him in isolation.
At the home of Sonya Marie Hughes, one of Dallas County’s nine epidemiologists, the phone rang. It was a special line, a twenty-four-hour emergency hotline that hospitals are supposed to call when they suspect an outbreak of some dangerous disease. Hughes called her boss, Wendy Chung. Chung, in turn, called the CDC in Atlanta: Ebola, she warned, might have arrived in America.5
When Chung arrived at the hospital, she was shaken by Duncan’s blood work. The patient’s platelets were low, something that might be caused by an infectious disease like Ebola. He was not throwing up yet, and there was no diarrhea. CDC operators in Atlanta weren’t worried yet, because Duncan had not attended a funeral before leaving Liberia.
Still, Chung needed to test Duncan’s blood for the presence of Ebola—and fast. Only one agency in the state, the Texas Department of Health in Austin, was capable of running a test for such a rare disease. But the department’s experts in Austin were not even sure how they were supposed to transfer the samples from Dallas, about three hours north by car. Finally, after conferring with an increasingly nervous CDC, they agreed to have it couriered south for testing.
In the hours that followed, Duncan’s condition deteriorated, and Chung’s fears grew. Overnight, the patient began exhibiting more violent symptoms. Isolation, no matter how delayed, had been the right decision.
On Monday, September 29, the CDC announced that a patient in Dallas was being tested for the Ebola virus. Results were due the following afternoon.
Texas Presbyterian’s staff was quickly overwhelmed with the incredible amount of work it took to care for just one patient in isolation. Among the nurses asked to aid Duncan, fear was becoming palpable. But they knew their calling, and they stuck to their work. All were given the opportunity to decline to treat Duncan. None shied away. The precautions they took got progressively more restrictive: first, nurses wore only masks, then face shields, positive-pressure respirators, another layer of gloves. The hospital had no full-body biohazard suits equipped with respirators.
On Tuesday, Duncan finally confided in one of the nurses treating him. He told her about Marthalene Williams, the young woman who had died after he helped her to and from the hospital in Monrovia. Chung blanched when the nurse relayed the story. At least seventy-six hospital workers had been exposed to Duncan while he showed symptoms of the disease—including
Chung herself. How many dozens more, including the five school-age children who lived in Troh’s apartment and the three-person EMT squad who had brought him to the hospital, had been exposed?
After calling the CDC, now convinced that Duncan had Ebola, Chung donned as much personal protective equipment as she could find and walked into the unit where Duncan lay. She began interviewing him herself: Where did you go? Whom did you speak with, touch, come into contact with? Dallas’s top epidemiologist knew she was racing the clock to trace Duncan’s contacts, to prevent an outbreak on American soil.
At the same time, she knew she would have to monitor herself for signs of the disease for the next three weeks.
Hours later, the blood work returned, and the CDC confirmed Chung’s worst fears. The man in the isolation ward had Ebola. A rapid response team, headed by the legendary epidemiologist Pierre Rollin, dispatched immediately from Atlanta. That night, an increasingly anxious state saw its governor, Rick Perry, holding a press conference at the hospital, trying to reassure his constituents that every possible precaution was being taken.
On Wednesday morning, Gary Weinstein, the doctor in charge of Duncan’s care in the hospital’s Medical Intensive Care Unit, reviewed his treatment options, slim though they were. A blood transfusion using blood from someone who had recovered and built up antibodies was not among those options. Neither Kent Brantly nor Nancy Writebol, the only two Americans with antibodies, matched Duncan’s blood type. ZMapp, the drug that may have saved both of them, was not a choice either because the supply of the hard-to-create drug had run out. The CDC recommended against another drug, TKM-Ebola, which would probably have made Duncan even worse.
The only option, he concluded, was brincidofovir, an experimental drug that had never been tested in humans.6 Manufactured by Chimerix, a North Carolina–based firm, the drug would stop the virus from replicating—if it worked at all. Even before they gave the drug to Duncan, hospital administrators would have to jump through a series of hoops, filing reams of paper required to grant what is called an Emergency Investigational New Drug Application with the Food and Drug Administration. (When news of the possible intervention leaked, Chimerix’s stock rose sharply.)
Outside the hospital, in Vickery Meadows and around the neighborhood, Chung’s team and experts from the CDC began tracking down everyone who might have had contact with Duncan. Initially, they believed that number might be small, no more than two dozen people. Eventually, they found more than one hundred people Duncan had been around—all of whom would need to be monitored for the next three weeks.
Though the CDC was in town, it quickly became apparent to local officials that the agency was not about to take over the entire response. Even if the CDC was equipped to take on such a mammoth task, they lacked the authority to do so. That hit home during a conference call, when Texas health commissioner David Lakey suggested establishing an incident command structure that would put one person in charge. Clay Jenkins, the Dallas County judge—the chief executive of local government—loved the sound of that idea.
“Well, who’s going to be in charge?” Jenkins asked on the call.
Tom Frieden, the CDC’s director, spoke softly: “You would be in charge,” he told Jenkins.7
“Everyone thinks the CDC comes and takes charge,” Lauren Trimble, Jenkins’s top aide, later told a journalist. “That was our assumption. Well, they don’t. They’ll help, sure. But we still have to do it.”8
Once the enormity of his task had set in, Jenkins began re-creating a response the county had executed a few years earlier, when a flu sickened hundreds around Dallas. The county set up an emergency operations center on the third floor of their building downtown. Their first job would be to take care of Troh’s apartment.
The apartment itself posed the greatest immediate threat of spreading the disease. It was where Duncan had spent days sweating, possibly bleeding, possibly excreting other bodily fluids. They would need to sanitize the entire space, though those who had shared it with Duncan while he became more and more contagious would have to be quarantined. Troh’s family, unable to leave the house, had to rely on donations from a local food bank.
Health officials dropped off fliers to residents at the Ivy Apartments warning about the dangers of Ebola and offering pointers on how to protect themselves. Many of the residents, though, did not speak English as a primary language, making it difficult to comprehend the fliers they had been given.
The county also needed to tamp down a growing sense of panic that was clearly infecting their populace. One of the young boys in the household had gone to school at Tasby Middle School on Wednesday; school officials had to send him home. The children in Troh’s apartment attended four different schools; attendance at those schools plummeted from a daily average of 96 percent to 86 percent as nervous parents kept their children at home. Students told reporters waiting outside those schools that other children, the children of African immigrants, were being bullied.9
The panic was spreading, too, to other parts of the country—and with a month to go before American voters cast ballots in midterm elections, the public’s reasonable fears were being inflamed for partisan gain. Perry established a state task force to combat infectious diseases and called on the Obama administration to create enhanced screening facilities for travelers coming back from West Africa, accompanied by fully staffed quarantine stations. Senator Jerry Moran of Kansas, who headed the Republican Party’s Senate campaign arm, and Representative Frank Wolf of Virginia demanded that the White House appoint a single adviser in charge of the response to the outbreak. (They suggested three senior statesmen, Mike Leavitt, Robert Gates, and Colin Powell—all Republicans.) Senator Ted Cruz, the ambitious young Texas Republican, asked the Federal Aviation Administration what steps could be taken to prevent passengers potentially infected with the virus from coming to the United States.
Republican candidates running for Senate seats in North Carolina and Michigan began calling for a ban on travel between the United States and West Africa. Influential members of Congress in charge of committees that oversee commercial aviation agreed: “We believe a temporary travel ban for such individuals who live in or have traveled from certain West African countries is reasonable and timely,” Pennsylvania Republican Representative Bill Shuster and South Dakota Republican Senator John Thune said in a letter to the administration. Representative Dennis Ross, a Florida Republican, introduced legislation to restrict commercial flights and travel visas for anyone from Liberia, Guinea, and Sierra Leone. House Speaker John Boehner said banning flights sounded like a good idea. (It did not seem to matter to any of those leaders that there were no direct flights from Monrovia or Conakry or Freetown to the United States; all passengers would have to connect through Lagos, or Brussels, or Paris, or London, and none of those countries had implemented travel bans.)
To humanitarian officials in charge of the response such as Anthony Fauci and Rajiv Shah, travel bans were exactly the opposite of what needed to happen. The flights were a lifeline, one that funneled medical responders into the places they were most desperately needed. Banning flights out of West Africa effectively meant banning doctors and nurses from flying into West Africa. They told President Obama that banning flights outright was a policy prescription that yielded no real results. During his first term, Obama had lifted a twenty-two-year-old ban on travel to the United States by those infected with HIV. At the time, he said, the policy was “rooted in fear rather than fact.”
But to political strategists, a call to ban flights played precisely to the fears most American voters harbored. Soon Republicans calling for a ban were joined by some Democrats—including Senator Kay Hagan, locked in a tight race for reelection in North Carolina (one she would ultimately lose). Polls showed 41 percent of Americans had “not much” or no confidence in their federal government’s ability to respond to the outbreak, including a majority of Republicans.
Only one Democrat, Arkansas Senator Mark Pryor, attacked Ebola
from the other direction. He accused his opponent, Republican Tom Cotton, of voting to take funding away from disease fighters at the CDC. In November, Pryor lost by seventeen points.
Outside the political realm, others began acting more irrationally. Navarro College, a small two-year community school sixty miles outside of Dallas, sent a letter to several applicants from Nigeria on October 2, informing them that their acceptances had been rescinded because they lived in a country with confirmed Ebola cases. A teacher at a Catholic school in Louisville, Kentucky, quit her job rather than take a twenty-one-day paid leave after returning from a medical mission in Africa. Geographic logic had no place at Saint Margaret Mary Catholic School. The teacher, Susan Sherman, had served her mission in Kenya, on the other side of the continent from the infected countries.
Dallas County officials had contributed to the chaos, too: CNN had aired an interview with Louise Troh, in the days after Duncan was admitted to the hospital, in which she claimed that her family was being quarantined inside an apartment still crawling with Ebola-laden bodily fluids. Health officials realized they had not even figured out what kinds of permits they would need to transport debris from the apartment to an incinerator. Troh’s family waited for days before health officials finally took away the sheets and towels on which Duncan had slept.10 By Friday, Hazmat crews cleared out the apartment, stuffing everything but the walls into protective bags, and then into barrels. They had to chainsaw through the television and the PlayStation as Troh’s family stood nearby, still in the clothes they had put on that morning.
Hours later, Jenkins had found a home for the family, thanks to Dallas mayor Mike Rawlings. Rawlings’s son had vacated a house he was renovating a few miles away; to transport the family safely, and without scrutiny from the news media flying helicopters overhead, Jenkins made a call to the White House. Soon, those helicopters got an order to vacate the area; a dignitary, they were told, might be flying into nearby Love Field, so they needed to clear the airspace.11
