Crisis in the Red Zone

by Richard Preston

  Kent Brantly began looking around the hospital grounds for a good place to set up an Ebola ward with a red zone for the biocontainment of patients. Eventually he decided to put the Ebola ward in the hospital’s chapel. Brantly made the chapel into a red zone—he put up plastic barriers, and moved medical supplies and protective gear into a storeroom near the chapel. The ward had five beds for Ebola patients. After that, Kent Brantly, Lance Plyler, and the rest of the Samaritan’s Purse staff watched and waited.

  April 12

  A Marine lieutenant colonel attached to the U.S. Embassy in Monrovia met Lisa Hensley at Roberts International Airport when she got off her flight. They loaded the transport chests into some Embassy vehicles, and the vehicles traveled a short distance along a dirt road out of the airport and into a tract of forest, and arrived at the Liberian Institute for Biomedical Research, or LIBR. The facility is a former chimpanzee research station that has been converted into the principal medical testing and research lab of the government of Liberia.

  Hensley and her colleague Joseph Fair met the staff and explored the facility. It is a collection of concrete buildings, which includes large chimpanzee houses that have barred doors and windows. The chimp research had been stopped, and the chimpanzees had been moved to an island in a nearby river.

  Several rooms at the former chimp station were now well-equipped laboratories for research on HIV. Hensley and Fair thought these rooms would be a good place for setting up a Hot Lab for testing blood samples for Ebola. They started unpacking their trunks, and they met a team of Liberian lab technicians who would work in the blood lab and would eventually take over the operation of the lab after Hensley had returned to the United States. That evening, an Embassy car took Hensley and Fair into Monrovia and dropped them at a hotel near the beach. The hotel would be their home for the coming weeks.

  Early the next morning, an Embassy car carried Hensley and Fair back to the former chimp station, and they began working as advisors to the team of Liberian government lab technicians, setting up the hot lab and showing the techs the equipment. The techs hadn’t done high-biosafety space-suit work before. Then, right in the middle of this, Joseph Fair suddenly left the assignment and instead went to work as an advisor to the Ministry of Health of Sierra Leone.

  Hensley continued working with the Liberian team, and together they created a hot lab. They sealed the windows and doors of a suite of rooms, creating an air-controlled lab. They installed negative-pressure HEPA air circulators, which lowered the air pressure inside the lab and filtered the air coming out. The filters would block any particles of Ebola or microscopic droplets of blood that might be in the air inside the lab, and keep them from escaping. They created a decontamination room, a gray room between the hot lab and the rest of the building, where they would spray their suits with bleach before removing them, to kill any Ebola on the outside of the suit.

  When they had finished the preparations, the Liberians and Hensley turned on the HEPA circulators and lowered the pressure in the lab, and then tested it to make sure the seals were good. The lab was now ready to go hot.

  Hensley showed her colleagues how to put on and take off a whole-body pressurized lightweight space suit. The suit had a battery-operated respirator attached to the waist of the suit—a PAPR. For a helmet, the suit had a clear, soft plastic bubble that surrounded the person’s head and provided a complete field of view. By April 15, three days after Hensley had arrived, the team had the LIBR Ebola lab at the former chimp station up and running, and they immediately began testing samples of human blood for the presence of Ebola virus. The samples were sent to the lab by doctors from all over Liberia.

  A few miles away from the former chimp station, doctors at ELWA Hospital, on the beach in Monrovia, were collecting samples of blood from patients and sending them to Hensley and the LIBR team. None of the blood that arrived at the LIBR lab came up positive for Ebola. It seemed to Hensley and the other observers that Ebola had gotten into a few people in Liberia and then had vanished. Hensley’s lab, so far, had not actually gone hot. It had not yet had Ebola virus in it.

  By the day Hensley arrived in Liberia, there had been ninety-four cases of Ebola reported in the country, with forty deaths. Seven of those cases had been in Monrovia, a city with a population of a little over a million. The virus had seemed poised to take off in Monrovia, but then the virus began to weaken in Liberia. In the last week of April, there were only thirteen new cases of Ebola reported in the whole country. The outbreak seemed to be fading.

  We now know that the virus in Liberia at that time was genetically close to the Zaire Ebola that jumped into the little boy in Meliandou. In other words, the first kind of Ebola to enter Liberia was wild Ebola, fresh from the ecosystem. The A82V Makona Variant, the Makona strain, the mutant, which had first appeared in Guinea just a few weeks earlier, was still jumping around the Triangle, and hadn’t made a breakout for the cities. And nobody knew the Makona strain existed.

  Hensley worked twelve-hour days in the lab. She found her Liberian colleagues to be dedicated professionals, very good at Level 4 lab operations. She didn’t feel disappointed by the fact they weren’t finding Ebola in the blood the doctors were sending to the lab, but it seemed as though she had missed a chance to get her hands on Ebola virus and actually fight it. Her hotel on the beach seemed pretty luxurious, though she didn’t have time to swim in the ocean. Every night before she went to sleep she called home using Skype. She told James she’d been wearing her sun hat, the one he’d packed in her duffle bag for her. She thought he seemed unworried.

  James was worried. One evening Hensley’s parents told her that he had had a hard time at school that day. His class had been studying the life of the Russian composer Tchaikovsky, who had died of cholera. The disease causes fatal diarrhea with sudden death, and James had gotten quite upset when he learned about the symptoms. Finally the teacher took him out of the room and asked him what was wrong. He had said that he was worried about his mother. Eventually the teacher brought him back into the classroom, and he told the class that his mother was in Africa helping people fight Ebola, a fatal disease that was like cholera. “I’m so proud of my mother,” he had said.

  On April 28, she flew back to the United States, having never found Ebola in any blood sample. Her Liberian colleagues continued blood testing operations in the Liberian national lab. Hensley returned to work at the Integrated Research Facility. She continued getting the research programs organized and started. She stayed in touch with her Liberian colleagues at the former chimp station. As the weeks passed, they saw no Ebola in the blood samples that were coming into the lab. Ebola seemed almost gone.

  MAKONA TRIANGLE

  Later April

  The sister of Menindor the healer, the sister who’d given care to Menindor and had washed her body, died in Kpondu some weeks after Menindor died. Menindor’s mother, who’d also given Menindor care, fell sick in her village, and died at some time in April or possibly in early May. On April 21, Menindor’s husband died. Nine days later, Menindor’s grandson died in Kpondu. By early May, the virus was hitting women in Buedu, Nyumundu, Kolosu, Fokoma, and Sasani. These women had been at Menindor’s funeral or were closely connected to women who’d been at the funeral. All of them died of the hot Makona strain.

  The death of Menindor’s husband impressed people and frightened them. Many people in the area believed that diseases were caused by malignant forces. They were aware of the story that Menindor had been keeping a supernatural snake inside a chest in her house. After she died, a story went around that Menindor’s husband had very foolishly opened the chest. The reptile had escaped and killed him, and now the snake of Menindor was going around the villages, planting its invisible fangs in people, destroying them. The villagers had their own explanation for what was happening.

  Even as the Makona strain was quietly amplifying itself in the villages, the number of new re
ported Ebola cases in West Africa continued to drop. Zaire Ebola, the Ebola that had gotten into the little boy in Meliandou, was starting to wane in the human species, even as the Makona strain was growing new chains of infection. One fish was pulling ahead of the others.

  In the hot lab at the Liberian national lab in the former chimp research station near the airport in Monrovia, the Liberian government technicians continued testing hospital blood samples for Ebola—but Liberia seemed to be free of the virus. In Kenema, Humarr Khan and Lina Moses continued to be on the alert for Ebola cases, and they continued to send surveillance teams out into the villages looking for signs of virus, but so far not a single case had been detected in Sierra Leone. With Ebola seeming to fade away, Humarr Khan decided to attend a scientific conference in Daytona Beach, Florida. He left Kenema on April 25.

  AMERICA

  May 2

  After the conference in Florida, Humarr Khan flew to Baltimore to visit with two of his sisters, Isatu and Umu, and a brother, Alpha. Alpha was working in sales in Baltimore, and he knew the city well. Maybe a little too well. Humarr stayed out late with his brother and did some bar hopping around the city, and they generally enjoyed themselves.

  Humarr’s brother Sahid, the IT manager in Philadelphia, was sixteen years older than Humarr, and he had taken on the role of a parent for his younger brother when Humarr was growing up in Sierra Leone. Humarr still addressed Sahid as “sir,” as he had done ever since he was a boy, and he also called Sahid by the nickname “Brother J.”

  Sahid began to get a little bit worried about Humarr, running around Baltimore with Alpha. Eventually he phoned Humarr for a talk. “Have you guys been doing all that stuff Dad says will send you straight to hell?” Sahid asked. (Their father was now ninety-nine and in good health.)

  “Not so bad, sir.”

  “Well, what did you do? You and Alpha?”

  “We only had a couple of beers to have fun,” Humarr answered.

  “What about marijuana? Did you smoke marijuana?”

  “No, sir. Never. I don’t smoke marijuana. I smoke cigarettes, sir. Alpha doesn’t even smoke cigarettes.”

  Sahid laughed gently. “Okay, look, I have no problem with having a good time. But I always like to preach moderation with you.”

  “Yes, sir.”

  Sahid was getting amused by all the sirs coming from Squazzo. “Sir? Who are you calling sir?”

  Humarr laughed. “Yes, Brother J.”

  Sahid had a feeling that his brother was vulnerable. For years, he had been worried that Humarr could die in the Lassa ward. And now there was Ebola to worry about. “America is safe from these things,” he said to Humarr on the phone. “Just stay here. Don’t go back to Sierra Leone. You can live near your sisters there in Baltimore.”

  “I don’t want to live here, sir.”

  “But you can come to Philadelphia. You can stay with me. I can help you get set up here. You can be a doctor here.”

  “They don’t need me in the cities of America,” Humarr answered his brother. “They need me for the Lassa fever over there.”

  “Yes, but do you know how much doctors are making here? Six figures.”

  “But I’m a trained virologist, sir.” He sounded completely confident in himself. “I’m very good at what I do.”

  Humarr had recently spent three years in Ghana getting advanced medical training. Sahid and their sister Umu had loaned him $17,000 to pay the tuition, since his paltry government salary couldn’t cover the cost. Sahid reminded him that in the United States a doctor can earn $17,000 with relative ease.

  “I have to pay for my training myself,” Humarr said. Committed to returning their gift, he had started a private practice in Kenema, and the income from the practice would eventually help him pay back the money. He also told Sahid that he would be returning to the United States in just a month—in June—to take a fellowship at Harvard with Pardis Sabeti.

  “When you’re in Cambridge, I hope we have more time to talk about your moving to the United States,” Sahid said.

  “Yes, sir. We’ll talk.”

  Sahid ended the conversation feeling that he missed his younger brother badly. He really didn’t like the idea of Humarr going back to Kenema.

  DARK WINGS

  KENEMA GOVERNMENT HOSPITAL

  May 7

  After his visit to the United States, Khan returned to his duties at the hospital. The Ebola outbreak seemed to be fading. On May 7, health authorities in Conakry reported that the number of new Ebola cases in the city was dropping sharply: The city was seeing only about one new case a day. In Liberia, Ebola had disappeared. And not a single case of Ebola had been reported in Sierra Leone.

  KPONDU VILLAGE

  May 7

  One of the leaders of the Kenema surveillance team was a man named Michael A. Gbakie. A soft-spoken man in his forties, with a quiet demeanor and a sensitive gaze, Gbakie (pronounced “Bocky”) was the chief biosafety officer in the Lassa research program. He traveled in a white Land Cruiser with a driver and, typically, another surveillance officer. They stopped in villages and described the signs and symptoms of Ebola, and asked if anybody knew of or had seen anybody with this disease.

  On May 7, Michael and his team learned that there had been some deaths in a tiny village, Kpondu, in an area called the Kissi Teng Chiefdom. They drove to Kpondu, and found a few small, rectangular houses with metal roofs arranged around an open space. Next to the houses stood cooking sheds roofed with palm fronds—in the tropical climate, people did their cooking outdoors. The team identified themselves as being from the Ministry of Health and said they were looking for a disease called Ebola. They described the signs and symptoms, and asked if any deaths had occurred in the village recently.

  The residents said that a famous healer, a woman, had died in the village. She had been a leader of women. Her name was Menindor. She had become sick and died.

  Michael and his partner asked the villagers about the cause of death of this healer: Did it seem like Ebola?

  No, she had failed with the law of the smoke, the villagers said.

  Michael had no idea what that was. He wasn’t going to argue with the villagers about their explanations for diseases. He just wanted to know if the healer’s disease had seemed like Ebola.

  No, it wasn’t Ebola, the villagers said. In addition to failing the law of the smoke, the healer had failed her responsibility with the snake, and this was the cause of her death.

  Michael had absolutely no idea what they were talking about.

  Menindor’s husband had also died, they said. He had opened his wife’s bag, or chest, and had seen the snake inside it. Her husband saw the snake and that was why he had died. And then a little boy had died. The reason for the boy’s death was that Menindor had prepared a magic flagstone and placed it in the lintel of the door to her house. Menindor’s magic stone had been removed from the doorway and this had caused the boy to die, they said.

  Gbakie and his partner were using a translator who was helping them with the Kissi language. Using the translator, they said, “But we want to tell you that Ebola is close to you,” they said. “You have to be very watchful for Ebola.” If anybody had symptoms of this disease, they should go to the community health clinic in a town called Koindu. The head of the Koindu clinic was in contact with Humarr Khan, and would report any Ebola-like diseases to Khan if he saw them in his clinic.

  Michael Gbakie and his team returned to Kenema on May 8, thinking that the death of the healer Menindor had occurred a short time before then. In fact, her death had occurred exactly a month earlier, on April 8. The Makona strain had been moving out of her funeral for a month, and had not yet been noticed. It seems that the villagers were aware of Ebola, but possibly they didn’t want to disclose all they knew out of fear they would end up in a camp. And so Michael Gbakie and his team had com
e close to the Makona strain, but it had slipped past them.

  * * *

  —

  By the third week of May, the outbreak seemed essentially over. During the entire time of the outbreak, there had been a total of 258 cases of diagnosed or probable Ebola in West Africa. Zaire Ebola was acting just the way it had acted in all previous outbreaks: a couple of hundred people get Ebola, and the virus goes away, suppressed by the Ebola fighters. The World Health Organization prepared to announce the end of the outbreak; the announcement was planned to come at the end of May. Doctors Without Borders made plans to start closing their Ebola treatment units and bringing their staff home.

  The dry season was ending in West Africa, too. The rains arrive in Kenema during the last few days of May. As May 2014 came to a close, the sky remained blue and cloudless. But as the days went by, the hot, dry air grew a little strange, a little restless, got a prickly feeling. The sky was a smooth blue void, except for egrets flying, small white things moving high up. A local legend said that the egrets were watchers who looked down on the world and protected all the other animals on the earth: cattle, goats, crocodiles, lizards, even snakes. The protection of the egrets did not extend to the flies, however. The flies were too small and too numerous for the egrets to see them or keep track of them. Thus it was said that the flies had to look after themselves, and they were well able to do that. At night, when the city became quiet, Equatorial stars glittered in a black, cloudless sky, and heat lightning flashed in the southwest, a sign of approaching storms. After so many months of heat, of smoke from burning fields hanging in the air, and a lion-colored sky filled with dust blowing in from the Sahara Desert, people ached for rain. They wanted the world to be lashed with storms and turning emerald green; and they wanted to hear the roar of water pouring through the gutters that ran along the streets, washing all the grime out of the city.