Epidemic

by Reid Wilson

  The family spirited down a back stairwell, escorted by Jenkins into an idling SUV. It drove them the half hour to the new house, a small four-bedroom affair where the family could complete its quarantine out of sight of the media—and, importantly, in a safe, clean environment.12

  In the hospital, Duncan continued to fight, and he tried to stay upbeat, though his body was failing him. On Tuesday, he asked doctors to play an action movie. On Wednesday, he told his nurses he was hungry—a positive sign that he might be staging a comeback. They fed him a packet of saltines and a can of Sprite, though he managed to take just a few sips.

  The outward signs betrayed the extent of the damage the virus was causing. There was blood in Duncan’s urine, and doctors began to grow worried about his lung function. By October 4, his condition was downgraded from serious to critical. His organs began failing, just as the supply of the experimental drug, brincidofovir, arrived.13

  Two days later, on Monday, October 6, Duncan’s mother, sister, and nephew arrived at the hospital, after driving all night from North Carolina. Doctors only allowed them to see the rapidly deteriorating Duncan through a closed-circuit television monitor. Finding her son glassy-eyed and virtually comatose, his mother Nowai Korkoyah dissolved into inconsolable sobs: “My son is dead!” she wailed.14

  Nurses cared for Duncan around the clock. He was heavily sedated, tears running down his face. By Wednesday morning, his pulse had dropped to the mid-forties. The brincidofovir kept dripping through his intravenous, but doctors realized that their last hopes were diminishing rapidly. Duncan’s blood pressure suddenly dropped, a terrible indication of what was to come. One of the nurses, John Mulligan, wiped the tears away from Duncan’s eyes. It would all be okay, Mulligan told Duncan.

  Fifteen minutes later, at 7:51 a.m. on October 8, 2014, Thomas Eric Duncan’s heart stopped.

  Jenkins and Troh’s pastor made their way to the home across town a few hours later. They sat away from Troh, to avoid becoming exposed themselves, and told her the man she loved was gone. Troh lost it. Her son, Karsiah, had not been able to see his father before he died. The closest he came was signing papers allowing Texas Presbyterian to cremate the body.

  Dallas County officials were not yet out of the woods. Still within the incubation period were 177 people who had come into contact with Duncan—friends, neighbors, children, and medical personnel. They checked their temperatures religiously, monitored by everyone from the county health department to the CDC in Atlanta. Every cough, every ache that would otherwise pass unnoticed became cause for concern.

  It was a young nurse, one of those who had treated Duncan, who began to feel unwell first.

  Nina Pham had a reputation for getting things right, for double- and triple-checking patient charts to avoid mistakes. The twenty-six-year-old daughter of Vietnamese refugees had earned her degree in nursing from Texas Christian University; friends there credited her with inspiring them, and even teaching them, to be better nurses. Just two months before Duncan had arrived, she had received her certificate in critical care nursing.

  But on October 10, Pham developed a low-grade fever. She called one of Dallas County’s epidemiologists to warn her; when Pham’s temperature hit 100.5, she drove herself to her own hospital, where she was put in isolation just ninety minutes later. Jenkins and the epidemiologists were stunned at the news: Pham had not been on the list of those who might have been exposed.15

  Doctors raced to treat her aggressively, assuming the worst. Three days later, the day after the CDC confirmed that Pham had become the first person to contract Ebola inside the United States, she received a blood transfusion from Kent Brantly; unlike Duncan, Pham’s blood type matched Brantly’s, and within hours Ebola-fighting antibodies were coursing through her veins.

  On the same day, one of Pham’s colleagues, Amber Joy Vinson, boarded a Frontier Airlines flight from Cleveland to Dallas. A Kent State graduate from the small town of Tallmadge, Ohio, Vinson, age twenty-nine, had returned to her childhood home to plan her wedding; she visited a bridal store to try on dresses while she was there.

  During her time at home, Vinson had begun feeling unwell. Her temperature also began rising, to 99.5 degrees. The day after she arrived home, Vinson’s fever went up again; it took about twenty-four hours for blood tests to reveal that she, too, had Ebola.

  The fact that Vinson had traveled twice, from Dallas to Cleveland and back, alarmed CDC doctors, and spooked the media. Federal authorities raced to track down about 150 people with whom Vinson had come into contact in Ohio, including 87 people on the two Frontier airplanes she flew. (The airline took one plane out of service and replaced seat covers and carpet near where Vinson had sat.) A Transportation Security Administration agent in Cleveland, who had patted Vinson down on her return trip, was placed on a three-week paid leave. So were the six members of the Frontier flight crew, four flight attendants and two pilots, who flew from Cleveland to Dallas.

  At the same time, another lab worker who handled the Liberian man’s blood had departed on a cruise a few days before; when she started feeling unwell, the lab worker quarantined herself in her cabin until the cruise ship neared Galveston, Texas. Federal officials had already asked the governments of Belize and Mexico to allow the lab worker to disembark; both countries said no. Governor Rick Perry refused to allow the ship to dock with a potentially Ebola-infected person aboard, so the Coast Guard dispatched a helicopter to pick her up. She never developed symptoms.

  There is an old and cynical saying in the news media: If it bleeds, it leads. Vinson and Pham quickly proved that blood need not be spilled to provoke a frenzy, much of it centered on rumors that proved inaccurate. Reports that Vinson had traveled against doctors’ orders turned out to be false; she had been given approval to fly home by a CDC physician.

  Still, the media publicly fretted about the prospect of so many who had come into contact with Duncan traveling freely across the country. Both Ohio and Texas implemented new rules restricting travel for anyone who might have been exposed.

  In truth, the physical characteristics of Ebola make it susceptible to oxygen, making transmission unlikely, though not impossible. But calm and rational analysis of medical facts are tough to fit into a breaking news headline on television.

  A debate was brewing, both on public airwaves and on the conference calls between senior medical officials, over how Pham and Vinson had been infected. No one knew for sure; neither nurse could remember coming into direct contact with Duncan’s bodily fluids. The CDC’s Frieden had seemed to suggest, the day after Pham fell ill, that the nurses had not properly protected themselves. He apologized a day later for seeming to blame the nurses for getting sick, though Frieden and Anthony Fauci continued to believe they had not followed protocols.

  Duncan’s infection, and the subsequent infections of Vinson and Pham, deeply shook the White House and those who believed that the U.S. hospital system was better prepared to catch any potential Ebola cases. “We all had the impression that any hospital would not only be able to recognize that somebody was infected with Ebola, but take appropriate precautions,” said Amy Pope, the president’s deputy homeland security adviser. “We had gone into it with the assumption that U.S. providers would be able to recognize the signs of Ebola.”

  Texas Presbyterian had missed those signs.

  “Basically, the facts showed we were wrong on two counts: One, the hospital did not do the travel history [on Duncan], so they basically missed it the first time he was at the hospital. So they didn’t recognize from the outset, so that made clear to us that we needed to put some other triggers in place,” Pope said. “The second piece was, what kind of infection control did they exercise?”

  The patients, Pham and Vinson, were lucky that their symptoms were caught early. Duncan had been sent home to fight the virus alone for three days. Now, hypersensitive to the possibility of Ebola’s spread, doctors intervened the moment both women showed any signs of infection. And where the CDC had
been caught off guard by Duncan, they were more ready to treat new patients—just not at Texas Presbyterian.

  Only a handful of facilities around the nation are capable of treating a patient under biosecurity level-4 conditions: the Nebraska Medical Center, Emory University in Atlanta, the National Institutes of Health (NIH) in Bethesda, Maryland, just outside of Washington, and the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) at Fort Detrick. The Nebraska facility was already treating one patient, Ashoka Mukpo, a freelance cameraman who had contracted Ebola while on assignment in Liberia. The NIH offered to take Pham; she arrived in the Special Clinical Studies Unit, on NIH’s Washington-area campus, on October 17, about a week after her first symptoms. Vinson would be sent to Emory, where she arrived on October 15, just a day after being diagnosed.

  Instead of simply isolating patients, all four hospitals were practicing what they called “supportive care,” an intensive treatment regimen aimed at keeping the body strong enough, long enough, to develop its own antibodies. Doctors worked hard to maintain vital signs like breathing and blood pressure, to ward off the hemorrhaging and organ shutdown that progressed during advanced stages of infection. Treating a patient with so much attention required an around-the-clock staff effort; in Bethesda, about twenty-seven people per week treated Pham.16 In Atlanta, Vinson too received blood transfusions from both Brantly and Writebol.

  Pham was most worried about her dog, a Cavalier King Charles spaniel named Bentley. A week earlier, a dog belonging to a Spanish missionary who was fighting for his life after returning from West Africa had been euthanized; health officials there were worried that the Ebola virus might lurk in the dog’s blood and infect someone new. Pham did not want her dog to suffer the same fate. Jenkins, the Dallas County judge, was also determined to save the dog, for public relations purposes if nothing else.

  Fortunately for Bentley, the U.S. Army Medical Research Institute for Infectious Diseases had an answer. The diagnostic tests that the Army scientists had prepared before American troops were deployed to Liberia would also indicate the presence of Ebola in dog blood. USAMRIID had run those tests in case the 101st Airborne had taken Army working dogs with them on deployment. (Ultimately, the military decided against taking their dogs.) Army doctors and veterinarians kept Bentley in quarantine for three weeks, testing his blood from time to time to see if he had picked up Ebola. The virus never showed itself in the dog.

  Both Pham and Vinson, overseen by teams of dedicated doctors, recovered remarkably quickly. In just a week after arriving in Bethesda, five straight blood tests showed the Ebola virus had left Pham’s bloodstream. Nine days after she arrived at Emory, Vinson, too, was declared virus-free.

  Pham walked out of the NIH facility under her own power on October 24, two weeks after first falling ill. At a press conference surrounded by the doctors who treated her, Pham—showing no outward signs of the aftereffects of the virus—read a brief statement. Fauci, among those who had treated her, made a point to put his arm around her, to demonstrate there was no risk in touching a survivor. “She has no virus in her,” Fauci said at the press conference. She was reunited with Bentley when she returned home to Dallas.

  Four days later, Vinson, too, walked out of Emory looking healthy, if shaken. She wiped away tears as she thanked God, her family, and the medical team that nursed her back to health.

  In Washington, with an election around the corner, Republicans began ratcheting up pressure on the White House. Privately, even Democrats were worried that President Obama’s response was missing the mark. What the White House sought to convey was a president executing a calm and steady response, driven by science and not irrational fear and panic. What the public saw, more often, was an aloof executive detached from the rising panic his constituents felt.

  Obama tried to make clear that he took the threats seriously. The day Pham arrived in Bethesda, Obama canceled out-of-town fundraisers for Democratic candidates in Rhode Island and New York. He also signed an order that gave the Pentagon the authority to call up National Guard troops, if needed, to fight the outbreak.

  Publicly, the White House still projected outward confidence. Most strikingly, Obama hosted Pham in the Oval Office. A woman who had been diagnosed with the most dangerous virus in the world just two weeks prior was photographed hugging the president of the United States of America. The photograph led all three nightly news broadcasts. He called Vinson, too, when she was released.

  Back in Dallas, what could have turned into the first full-scale outbreak of the Ebola virus in American history, perhaps miraculously, did not. Days went by, with Jenkins, Rawlings, and their staffs on high alert. The first potential contacts, those who had been near Duncan as he deteriorated, began to emerge from quarantine with no symptoms. After three weeks, all 177 contacts were clear.17

  But while scientists were beginning to understand the Ebola virus more intimately than ever, Pham and Vinson presented a new mystery: Was it the fast treatment they received that helped them recover so quickly? Was it the antibodies they received through blood transfusions from Brantly and Writebol? Was it the focus on keeping vital signs at healthy levels, to give their bodies the time to develop their own antibodies?

  The experiences of Pham and Vinson, and of Brantly and Writebol before them, had taught scientists one valuable lesson: Providing support, no matter how ill a patient, was worth the effort.

  “The general dogma in our industry in July was that if patients got so ill that they required dialysis or ventilator support, there was no purpose in doing those interventions because they would invariably die,” Bruce Ribner, medical director of Emory University Hospital’s Serious Communicable Diseases Unit, said at a press conference. “I think we have shown our colleagues in the U.S. and elsewhere that that is certainly not the case, and therefore, I think we have changed the algorithm for how aggressive we are going to be willing to be in caring for patients with Ebola virus disease.”18

  What Ribner meant was: If the worst happens, we know how to treat the Ebola virus. It was an important message for the world, both in the United States and for nongovernmental organizations still trying to decide how to be helpful in West Africa.

  But at the same press conference, Ribner betrayed just how much the medical community had left to learn about the virus that had now breached American shores. Asked why Pham and Vinson had recovered so quickly, Ribner admitted: “The honest answer is that we’re not exactly sure.”

  That uncertainty bedeviled the White House. The government’s confidence in its ability to prevent an outbreak on American soil had been deeply shaken, and now they wondered whether the military—already setting up Ebola treatment centers at breakneck speed on the other side of the Atlantic—might have to build similar facilities back home.

  “Because our confidence was so undermined by what happened in that Dallas hospital, the fact that two health care workers became infected in the hospital, created a situation of, we really don’t have that much insight into the way our hospitals do business,” Pope said. “There was a question of, could there be other Dallas cases?”

  FOURTEEN

  The Ebola Czar

  INSIDE THE WHITE HOUSE, President Obama was not happy. By early October, a little more than six months after the World Health Organization (WHO) announced Ebola’s presence in West Africa and about two months after the U.S. government ramped up its own efforts, political pressure was rising rapidly. In Liberia, the Ebola virus had shifted from northern Lofa County south into Bong County, while the number of cases in Monrovia spiked to more than 1,000. Back home, Obama’s aides had worked hard to convey the impression of a federal government that had a handle on the crisis and could protect the American public from danger. But with an election just a month away, that impression was not sinking in.

  Opposition Republicans seized on two concurrent crises—the Ebola outbreak and the rise of the radical Islamic State terrorist organization in Iraq and Syria—to sow unease amo
ng the American electorate. Public opinion polls showed that voters were pessimistic about the direction of the country to begin with, a trend borne of a deep economic recession from which America was only just beginning to recover. Throw in a killer virus and a pack of thugs rampaging through the Middle East with designs on harming Americans, and voter anxiety began reaching new heights. For an incumbent party, that anxiety can translate into a rout at the polls. Democrats held a narrow majority in the United States Senate, and party strategists tasked with preserving that majority warned the White House that anything less than an all-hands-on-deck response would cost them seats.

  Already, Republican candidates, beginning in Michigan and North Carolina, started using the outbreak in West Africa to attack their opponents. Amplifying that message, Republicans in Congress criticized the Obama administration for being slow to react, and for taking what they characterized as a disengaged approach to protecting American lives. Slowly at first, then more rapidly, Republicans started calling for a total ban on travel between the United States and West Africa. Some Democrats, sensing the political danger, joined the chorus. (Virtually every Democrat who called for a travel ban lost their election bids anyway.)

  The American response to the Ebola outbreak, both in the United States and in Africa, was anything but hands-off. But the impression the White House sought to convey—cool, collected, no panic—sometimes felt more blasé than Obama and his aides intended. They meant to demonstrate to the public that everything was well in hand, that the president was not panicking. It was an attitude that extended from the president himself, a cerebral man who depended on rationality and science to guide decision making, both his own and that of the emergency responders at the Centers for Disease Control and Prevention (CDC), the United States Agency for International Development (USAID) and the Pentagon.