Crisis in the Red Zone

by Richard Preston

  After praying, he went into the parlor. The room was dark and the curtains were closed. The room had a tiled floor, and it held a few pieces of furniture and a flat-screen television.

  “Morning, Doctor,” his houseman, Peter Kaima, said.

  “Morning-o.”

  Kaima fixed a cup of instant coffee for Khan and handed it to him. While Khan drank the coffee, Kaima took a chicken sandwich out of the refrigerator for Khan. Khan put on a white baseball cap and slipped the sandwich into his office bag. Then he went outdoors to a courtyard, where an ambulance was waiting. It was a white 4x4 Toyota Land Cruiser with a diesel engine and rugged tires, a type of vehicle known in Africa as a bush ambulance, because it can go places nobody would believe. Khan climbed onto the front seat and chatted with the driver as the ambulance went down Sombo Street and turned onto Combema Road, a wide, dusty thoroughfare lined with small shops. Kenema is a maze of dirt streets and metal roofs. Rush hour was just starting, and people were walking along the sides of the road and were riding on bicycles and motorbikes, heading for jobs all over the city or heading out of the city to work in fields. The Kambui Hills, soft whalebacks covered with tropical forest, were beginning to catch a glow of first light. A smell of smoke from cooking fires drifted in the air, mixed with motorbike fumes and dust. This was the dry season of the year.

  The ambulance went through the gates of Kenema Government Hospital. It is a sprawl of one-story stucco buildings surrounded by a high wall. The buildings are painted yellow and brown, or white and blue, and are linked by covered outdoor walkways. Dirt roads wander around the grounds, and clumps of flowering mango trees are scattered here and there, their thick crowns providing pockets of shade.

  The ambulance dropped Humarr Khan by the adult wards, a group of low buildings near the center of the grounds. He went into the wards and began his morning rounds. The wards were large, open rooms that contained many beds lined up in rows. Nurses wearing pale blue uniforms were working in the rooms, tending patients and supervising their care. It was common for patients’ family members to work alongside the nurses, giving care to their loved ones. Khan examined patients, spoke with family members, and gave instructions to the nurses. He also took time to train the nurses on various aspects of medicine and patient care, and he encouraged them to ask questions. “If there is anything you have a doubt about,” he often said to the nurses, “I am ready to clear your doubts.”

  Humarr Khan was thirty-nine years old, a handsome man, not very tall, with a square face and a lively, intense manner. Khan’s eyes were large and sensitive-looking, and set deeply in his face, and were cowled with strong eyelids, which could give him a veiled look. He was often enthusiastic and outgoing, but he could be secretive, too. He was single—divorced—and had a girlfriend whom he never seemed to talk about. His white baseball cap was a kind of trademark. Another trademark of Dr. Humarr Khan was an old white Mercedes sedan fitted with chrome spinner hubcaps. When he drove his Mercedes around Kenema, wearing his white cap, there were few in town who didn’t know who that was. Khan loved soccer and was a passionate fan of A. C. Milan, the Italian soccer club. Some of Khan’s American friends called him Cee-baby, a nickname taken from A. C. Milan.

  As Humarr Khan did rounds in the general wards that morning, the hospital came alive. People walked in through the hospital gate or came in on motorbikes or in taxis. The hospital’s walkways and porticoes got crowded with the families of patients. There were always children crying, people waiting anxiously outside a ward for news of a loved one, people resting in the shade of the mango trees, bush ambulances raising dust on the dirt roads as they bumped slowly past the wards and pavilions. Food vendors and drink sellers circulated along the walkways, holding trays of sandwiches and bottles of soda, keeping their voices low for the sake of the patients.

  After he’d finished making rounds in the general wards, Khan walked across a dirt parking lot to his outpatient office. It was a white metal shipping container shaded by a roof made of woven palm fronds. The container had two windows and a door, but no air conditioner. Khan’s waiting room was a set of outdoor benches next to the shipping container, shaded by a palm-frond roof. A number of walk-in patients were sitting on the benches waiting to see him. Many of them had arrived before dawn.

  Inside Khan’s shipping-container office there was a desk, a swivel chair, and a small exam table. Khan’s walk-ins presented with dysentery, worms, skin sores, unexplained fevers, rashes, bleeding ulcer of the stomach, liver flukes, bacterial infections, spinal meningitis, heart failure, HIV, AIDS, and cancer. Patients with serious conditions often went to herbalists and faith healers first, and by the time they got to Khan’s office it could be too late. He saw women with breast cancer whose tumors had broken through the skin, and he saw men with prostate cancer that had spread into their spines, leaving them paralyzed. He did what he could. For advanced cancer patients he prescribed palliative care. If a cancer patient could afford the cost, he’d send the person to Freetown, the capital of Sierra Leone, for treatment.

  If a patient was thin or looked hungry, Khan would dig into his pocket and peel a few bills off his ever-present wad of currency and tell the patient to go buy some food. “You must eat or you cannot get well,” he said to them. He also gave money to his patients so they could buy the medicines he prescribed for them. He took the money out of his salary and out of earnings he got from a private clinic he was running in town. A course of life-saving antibiotics could cost as much as twenty-five dollars. Not everybody in Kenema had immediate access to twenty-five dollars to save their life.

  * * *

  —

  While Khan was rounding the general wards, a woman named Mbalu S. Fonnie was doing rounds in the hot zone of Lassa Fever Isolation Ward, a small white building that sat next to Khan’s cargo container. Mbalu Fonnie was the supervisor of the Lassa ward, and she was an internationally respected expert on the clinical care of hemorrhagic Lassa patients in a high-biocontainment hospital ward. At the moment, she was wearing a cotton surgical gown, rubber boots, a surgical cap, double surgical gloves, eye protection, and a HEPA mask—a high-efficiency breathing mask that can stop a virus particle from getting into your lungs. Fonnie was a small, roundish woman in her late fifties, a very quiet person, deeply serious, a Christian, and she almost never smiled or laughed. She had once almost died of Lassa hemorrhagic fever. Having been carried to the edge of death by the virus, Fonnie thought she might have gotten some resistance to it now—but it’s impossible to become fully immune to Lassa virus. She had been running both the Lassa ward and the hospital maternity ward for twenty-five years. Many younger people in town had been born under her watch in the maternity ward, and some of them had been born into her hands. Most people called her Auntie Mbalu or simply Auntie.

  The hot zone of the Lassa ward consisted of a single, narrow corridor lined with nine small cubicles that opened on either side of the corridor. The patients lay on beds in the cubicles. The hot zone had a normal capacity of twelve patients—some of the cubicles held two beds, placed close together and almost filling the cubicle. There was a washing station with running water, where nurses could wash blood, feces, or vomitus off their gloves. At one end of the corridor there was an overflow room, and there was also a private nook, which was out of sight of the other beds in the ward.

  On this morning there were only two patients in the ward, both suffering from Lassa fever. Two nurses were tending them. They wore the same kind of surgical outfit that Auntie wore. Like Auntie, all the nurses in the Lassa ward were survivors of Lassa fever, and so they were thought to have a bit of resistance to the virus.

  Auntie examined the two patients. Then she walked to the end of the corridor, to the exit door of the hot zone. She opened the door and stepped outdoors, into fresh air, crossed a small space, and went inside a cargo container. The container was the dressing room and staging area for the hot zone. There, she remov
ed her surgical gear. Underneath she was wearing a flawlessly clean, starched white nurse’s outfit. She put on a small white nurse’s cap, and went outdoors and around the corner to the main entrance of the Lassa ward, where she went into a foyer and sat down by the nurses’ charting table and waited for Humarr Khan. Every morning they met in the foyer of the Lassa ward.

  After seeing walk-ins, Khan went next door to the Lassa ward and found Auntie sitting at the table. This morning he had big news. Yesterday the World Health Organization had announced that the disease in Guinea wasn’t Lassa fever, as Khan had first suspected, but was Ebola hemorrhagic fever. The disease was similar to Lassa but had a much higher death rate, and Ebola virus was much more infective than Lassa virus. And Khan told Auntie that Ebola had a long record of killing medical workers. The Lassa ward was the only high-biocontainment medical unit in Sierra Leone. The staff was well-trained and had years of experience handling bleeding, infectious Lassa patients. Auntie Mbalu Fonnie and her nurses would be the front line if Ebola reached Sierra Leone.

  Auntie was a person of very few words. She often spoke under her breath in a kind of whisper, and she had a British accent. She would have listened intently to Khan as he described Ebola to her, absorbing everything he said about the disease. His words were somber. When he had finished, she probably would have responded with something like, “Well, God will take control in this situation. God will drive it.” She also may have said to him, “God holds in God,” which was one of her favorite expressions. It means that God holds all the power and keeps his plans hidden until events come to pass.

  After meeting with Auntie, Khan walked downhill along a dirt road to a construction site in a corner of the hospital grounds, where a cluster of unfinished buildings stood. The buildings, sophisticated structures made of concrete blocks, would become a new Lassa ward. Khan walked behind a cargo container and sat down on a plastic chair, out of sight of the rest of the hospital, and lit a cigarette. Khan never let hospital staff or patients see him smoking. He’d put the chair behind the cargo container in order to create a hidden smoking place. As he smoked, he thought about Ebola. In the next hours and days he would be speaking to the entire staff of the Kenema hospital, getting them informed about the virus. He planned to read up on Ebola and talk with colleagues who were studying the virus. He would also look into possible experimental drug treatments, in case there was any sort of drug that might help save an infected patient.

  * * *

  —

  Humarr Khan had been running the Lassa program at the Kenema hospital for ten years. His predecessor had been a physician named Aniru Conteh. In 2004, a pregnant woman with Lassa hemorrhagic fever had a bloody miscarriage in the Lassa ward. Afterward, she had a profuse hemorrhage from her birth canal and went into shock from blood loss. There were no blood supplies in the ward, so Dr. Conteh couldn’t give her a transfusion. He decided to give her an intravenous infusion of saline solution—sterile salt water—to try to stabilize her. He placed the infusion needle a vein in her leg. After the infusion, he pulled the needle out of her leg. Then, acting from habit, he tried to put a plastic cap over the bloody needle in order to make it safe. The needle missed the cap, went through two layers of surgical glove, and pricked him lightly in the finger. Dr. Conteh hardly noticed the prick. Ten days later, he died of Lassa fever in his own ward, while Auntie Mbalu Fonnie and the Lassa nurses cared for him. They were crying behind their surgical masks as he passed.

  Afterward, an American doctor named Daniel Bausch set out to hire a new director for the Kenema Lassa program. Dan Bausch, a professor at the Tulane School of Public Health and Tropical Medicine, in New Orleans, was the American liaison to the Lassa program, and he had been a close friend of Dr. Conteh. He flew to Sierra Leone and started talking with doctors in the capital, Freetown, trying to find somebody who’d agree to replace Dr. Conteh. “If you had canvassed doctors in Sierra Leone about their dream job,” Dan Bausch said to me recently, “running the Lassa fever ward in Kenema would have been dead last for most of them.” Kenema was a remote city in the diamond fields, the government salary was pitiful, and the Lassa ward was now an obvious death trap for its director.

  After weeks of fruitless searching, Bausch ran across Humarr Khan. Khan was then twenty-nine and fresh out of his residency from the College of Medicine at the University of Sierra Leone. Bausch invited him to have a beer with him at a hotel in Freetown. After a brief chat, he offered Khan the job.

  Khan didn’t immediately accept. Bausch raised the stakes: He painted a picture of a possible future for Khan. Lassa was obviously a huge problem, and Khan would help save lives if he took the job. He would do research on Lassa virus with leading American scientists. He would speak at international conferences. He would likely become a co-author of scientific papers in top scientific journals. The government salary was terrible, Bausch added.

  Khan asked for a day or two to think about it. What he actually needed to do was meet with his father. A young man had to get his father’s consent for an important decision. His parents, Ibrahim and Aminata Khan, were living in a town by the sea on the far side of Freetown Bay, opposite the city of Freetown. Mr. Khan was 91, a retired educator with a national reputation, and he was a strict disciplinarian. Humarr was the youngest son among a total of ten brothers and sisters. They thought of him as their baby brother, bright but irresponsible, and some of them still called him by his childhood nickname, Squazzo. Now, he rode a rusting ferry across the bay, and took a taxi along a dirt road to a shady neighborhood of small houses made of cement blocks. In the sea just off the beach, fishermen in long wooden boats were setting nets, and smoke from cooking fires drifted through the neighborhood, mixed with a salty tang of the Atlantic Ocean.

  He sat down with his parents on the veranda, and spoke to them in Fulah, the family’s ethnic language. He told them about Dan Bausch’s job offer.

  Mr. Khan practically blew up. “It will be dangerous to work with Lassa virus!” he exclaimed in Fulah. “Look what happened to Dr. Conteh.” It had been all over the Freetown papers.

  “Don’t worry, sir. I know how to keep safe.”

  “You do not know how to keep safe!” Mr. Khan said heatedly.

  Ms. Khan agreed. She didn’t want her son going anywhere near Lassa virus.

  “Don’t do it,” Mr. Khan added.

  “But it’s what I want to do,” Humarr answered.

  In their view, this was the whole problem with Squazzo: He did what he wanted. They thought he had gone off the rails while he was in medical school in Freetown. He drank beer, he smoked cigarettes, he partied late at night with friends, he hung out at bars and nightclubs, and he had girlfriends. “You are headed straight to hell! Straight to hell!” Mr. Khan had warned him. Now, he urged his son to forget about Lassa fever and move to America. “Young people are coming over to the U.S. and making a lot of money.” Humarr’s older brother Sahid was living in Philadelphia, where he was an IT specialist. “Sahid can help you get established in Philadelphia.”

  “I don’t want to live in Philadelphia. I can’t work in an office, sir. I have to go out and be a doctor.”

  “So be a doctor in Philadelphia. Or Baltimore.”

  “I won’t go to America. I will stay here, sir,” Humarr said. The next day, he told Dan Bausch he’d take the job.

  A decade later, Dan Bausch’s predictions for Humarr Khan had come true: He was doing research with top American scientists, and some of them had become his close friends. He spoke at international conferences. He had co-authored scientific papers in top journals, though he hadn’t yet made it into Science, which would be a peak achievement in any scientist’s career. The government salary was indeed terrible, but he had set up a private practice in Kenema that was bringing him some income. As he settled into work in Kenema, Khan was very aware of what had happened to his predecessor, Dr. Conteh. He did not often put on PPE and go inside
the Lassa ward. One tiny accident in the hot area could cost you your life.

  * * *

  —

  After finishing his cigarette, Khan came out from his hiding place behind the cargo container and walked along a dirt road to the Lassa program office. It is a small, one-story stucco building with a palm tree growing in front of it. A few ambulance drivers and staffers were usually gathered under the tree, sitting on a bench and chatting, waiting for an ambulance call. Khan said hello to them and went into the office of the Lassa program coordinator, a young woman named Simbirie Jalloh. He asked her if there were any emails or phone messages. She told him that one of his scientific collaborators, an American woman named Pardis Sabeti, was setting up a conference call about Ebola, and she hoped he could join the call.

  SABETI

  CAMBRIDGE, MASSACHUSETTS

  9 a.m., March 24, 2014

  Over the years, Dr. Pardis Sabeti had forged ties with the Lassa program, and had become friends with Humarr Khan. When Khan joined her conference call, she was sitting at her desk in her office at her laboratory in the Northwest Building at Harvard University. Other scientists were speaking from other locations. Just then, Sabeti’s pet brown rat, Coco, was either asleep in her lap or was exploring Sabeti’s office, which the rat did fairly often. (“People probably think I’m psychotic, but I don’t do caged animals,” Sabeti says.) Pardis Sabeti was then an associate professor of biology at Harvard. She is a slender person, then in her late thirties, with a warm manner. She specializes in reading and analyzing the genomes of organisms. In addition to running a lab at Harvard, Sabeti leads viral genome efforts at the Broad Institute of MIT and Harvard. In particular, she studies virus evolution—the way viruses change over time as they adapt to their environments. In her spare time, she is the lead singer and songwriter for an indie band called Thousand Days. The band’s fourth album ended up getting delayed due to the Ebola outbreak.