Crisis in the Red Zone

by Richard Preston

  KENEMA

  May 20

  As the rains approached and Ebola disappeared, Lina Moses, the American scientist who was advising the Kenema surveillance team, began feeling deeply homesick. She lived in a small house in New Orleans with her husband, an artist named Aron Belka, and their two young daughters. She had been stationed in Kenema for months, and missed them terribly. She found Khan in the program office and told him she would be leaving.

  “I’d like you to stay longer,” Khan said to her. He was still worried about Ebola, he said. The virus hadn’t completely died out in Guinea, and it could still cross the river. If even a single case of Ebola popped up in Sierra Leone, there would have to be an intense search for the virus in the population. He really needed Lina Moses to stay in Kenema in case the virus appeared.

  Moses couldn’t stay. Her husband had been taking care of their daughters, driving to and from school and daycare, cooking, taking them to play dates, letting them play in his studio in the afternoons while he painted. She couldn’t bear to be without her children any longer. She left Kenema and took a series of flights home. A day and a half later she embraced her husband and children, weeping profusely as she held them, incredibly happy to be home.

  While Moses was in the air over the Atlantic Ocean, a twenty-year-old woman named Victoria Yilliah was admitted to the maternity ward of Kenema Government Hospital with a high fever and bleeding from her birth canal. She had been pregnant, and had gone into labor at the community health center in Koindu, in the Kissi Teng Chiefdom. Ms. Yilliah’s baby had been born dead, and had come out in a flood of hemorrhagic blood. Her husband, Anthony, brought her to the Kenema hospital.

  The staff of the maternity ward examined her. When they gave her an injection and set up an intravenous drip of saline for her, she had hemorrhages around the needle punctures in her skin—her blood had lost its ability to clot, and it ran steadily out of the needle holes. Her symptoms pointed to a fatal case of Lassa hemorrhagic fever. She was transferred to the Lassa ward, where she came under the care of head nurse Auntie Mbalu Fonnie.

  RAIN

  LASSA FEVER ISOLATION WARD

  May 23

  At the Lassa ward, Auntie put on PPE and examined Victoria Yilliah. It seemed almost certain that she would die. Lassa virus is especially lethal in women who are pregnant. The virus infects both the mother and her fetus, which dies and may be spontaneously aborted, while the mother has profuse hemorrhages from her birth canal and typically also dies. Nevertheless, Auntie had been able to save the lives of some infected mothers by giving them an abortion followed by a dilation and curettage, or D&C. A D&C is a procedure in which a curved scalpel called a curette is used to scrape out the inside walls of the uterus, removing any remaining fragments of the placenta. The Lassa rescue procedure was a risky, last-ditch effort to save the life of a woman who otherwise would probably die. If the fetus could be removed quickly, and a D&C performed afterward, the procedure seemed to offer the mother some chance of survival. The baby could never be saved.

  Ms. Yilliah had already lost her baby. Auntie decided to give Ms. Yilliah a D&C in an effort to save her life. She gathered a team; all donned PPE. Fonnie scraped out the patient’s uterus with a curette, assisted by her team, and the procedure went normally. Afterward, Ms. Yilliah rested quietly in a bed in the Lassa ward, tended by Auntie and her nurses. She didn’t die. Auntie wasn’t especially surprised by this. Victoria Yilliah fought for her life for days in the Lassa ward, and eventually she began to improve. In the end, she would survive her illness. She would be discharged from the ward in June and go home to her husband, Anthony. The D&C procedure seemed to be a factor in her survival.

  While Victoria Yilliah was fighting for her life in the Lassa ward, thunderstorms built over the Kambui Hills, piling up in white towers. Crackles of lightning ran from cloud to cloud, and thunder boomed, and a downpour fell over Kenema and pounded the hospital. The rains had arrived.

  The thunderstorm didn’t last long. Afterward the sun came out, and the metal roofs of the city steamed in the heat. But then another thunderstorm arrived. The rains came in waves, storm by storm, building up over the Kambui Hills, releasing sheets of rain. Lightning bolts started hitting the ground, and eventually the storms merged and produced steady downpours.

  As the rains rumbled, Khan got a phone call from the medical director of the Koindu clinic, where Victoria Yilliah had had her hemorrhagic miscarriage. He said that a female patient in his clinic had the symptoms of Ebola. Furthermore, he said, two women with Ebola-like symptoms had been taken out of the clinic by their relatives and had been brought to the Kenema hospital.

  This was really alarming. Khan asked the clinic director to send a sample of the sick woman’s blood to Kenema to be tested for Ebola. And it seemed that there were two women somewhere in the Kenema hospital who might have Ebola. Khan phoned a staff doctor at the hospital named Abdul Azziz Jalloh and asked him to immediately search the wards for any female patients showing signs of Ebola.

  Dr. Azziz rounded the wards, and discovered a woman who had classic signs of Ebola. “Her conjunctiva [mucous membranes of the eyelids] were inflamed, and she had a mask-like face, red eyes, diarrhea, vomiting, dry lips, and inflamed gums,” Dr. Azziz recalled later. The woman’s name was Satta K. He ordered a blood test and had her transferred to the Lassa ward. Satta K. ended up lying in a bed in the Lassa ward near Victoria Yilliah.

  The next morning, a messenger riding a motorbike left the clinic in Koindu. His motorbike held a plastic box, and inside the box there was a single glass tube containing an amount of blood that would barely cover a person’s fingernail. The blood had been collected from the woman with Ebola-like symptoms in the clinic; her name was Mamie Lebbie. She happened to be a sister-in-law of Menindor the healer, and she had been at Menindor’s funeral. The motorbike messenger hit thunderstorms, and reached Kenema in the late afternoon, and delivered the blood tube to the director of the Hot Lab, a man named Augustine Goba.

  Mr. Goba put on a white hazmat suit, goggles, double gloves, and rubber boots. Carrying the blood tube, he pushed open the door to the Hot Lab. A whisper of air flowed around him as he opened the door, traveling inward to the hot zone. He worked on the blood sample, preparing it for testing. This was a time-consuming process. It got late; he would continue the work the next day, which was a Sunday.

  HOT LAB

  KENEMA, SIERRA LEONE

  Sunday, May 25

  On Sunday morning, some of the nurses who came on duty at eight o’clock in the general wards sang hymns in order to lift the spirits of the patients and themselves as they began their day’s work. On Sundays, Muslims in Kenema tuned in to Christian radio stations and listened to gospel choirs singing in three-part harmony, just as, on Fridays, Christians in Kenema listened to the sermons of imams on the radio. As the morning went on, Christian families poured into the streets, walking to church. People were dressed well, men in sport shirts and slacks, boys dressed like their fathers, young girls wearing white or pink dresses, and women wearing long, brightly colored skirts and head wraps that matched. Some people were texting or talking on cellphones as they walked along.

  That morning, in a small lab inside a white cargo container in an alley next to the Lassa Laboratory, a French scientist named Nadia Wauquier (pronounced VOH-kee-ay) was preparing to join the effort to test the blood sample that had arrived from the clinic in the Makona Triangle. Nadia Wauquier was an employee of the American biotech firm Metabiota, and she was stationed in Kenema doing surveillance for emerging viruses. She had a PCR machine in her lab that could detect the genetic code of Ebola in human blood. For weeks, she had been using the machine to test samples of blood taken from patients at the Kenema hospital. She was monitoring the hospital’s patient population for any appearance of Ebola.

  Augustine Goba would run one test on the blood sample from the clinic in the Makona Tria
ngle using a PCR machine provided by Pardis Sabeti at Harvard. Nadia Wauquier would run a separate test on the blood using her machine. With two tests, the results could be cross-checked.

  Now, Nadia and her assistant, a female technician named Moinya Coomber, suited up in PPE and entered the Hot Lab. They began purifying a very small amount of the blood sample—a drop the size of a sesame seed—in order to test it. Augustine Goba arrived in the lab and began working with a separate droplet of the blood. The preparations took time, and there were seven other samples of human blood to prepare for testing as well—Nadia was continuing to do routine blood tests of patients in the hospital. Humarr Khan arrived and sat at a table in the Library, across the hall from the Hot Lab, waiting, wondering what was going on. Rain fell and stopped, and the sun came out.

  5:30 p.m.

  Nadia was in her cargo-container lab, holding a thin glass tube in her hands. It contained a purified extract of blood taken from Mamie Lebbie, the sick woman in the rural clinic. She fitted the tube into a tray of her PCR machine—a device about the size of a microwave oven. In the tray there were seven other thin glass tubes, each of which held a purified sample of blood taken from a patient at the Kenema hospital. These seven samples were just routine; Nadia had been testing patients’ blood for months, and not one sample had ever been positive for Ebola. She started the machine. It contained eight samples, in all.

  An hour later, just as darkness came, she saw that her machine had almost finished its run. By then, Augustine Goba and Humarr Khan had arrived in her lab. They gathered around a computer screen, and the finished results came up.

  As she looked at the results, Nadia could see that the test had gone wrong. Of the eight blood samples, three of them were positive for Ebola. One of the positives was for Mamie Lebbie. The other two positives were patients at the Kenema hospital. Three people with Ebola, two of them in the hospital?

  “This can’t be right,” Nadia said.

  They talked it over and decided these were false positives.

  “Let’s redo the test to be sure,” Khan said. Then he went outdoors, to an alley next to the lab, and phoned the minister of health of Sierra Leone, a woman named Miatta Kargbo. He had been keeping in touch with her all day, letting her know that Ebola might have arrived in Sierra Leone. “Madam Minister, there have been some technical issues. We are going to do the test again.”

  The minister was really unhappy. “I want you to stay by the lab, Dr. Khan,” she told him. “You have to be there right to the end of the testing.” She would be calling him every thirty minutes, she said. And she very much hoped the result would be cholera. Not Ebola.

  Augustine Goba now began his test of the blood; he would test only the blood of Mamie Lebbie, the woman in the clinic. He suited up and entered the Hot Lab. Meanwhile Moinya Coomber, Nadia’s technician, began preparing a fresh set of all eight blood samples, for the second test in Nadia’s machine.

  While the work went on in the lab, Humarr Khan went outdoors to the alley next to the Hot Lab, sat down on a step, and lit a cigarette. He was in turmoil. The minister of health was breathing down his neck. The Ebola outbreak was thought to be almost over. But if one person with Ebola was found in Sierra Leone, it meant an outbreak was happening. How many people were out there in the villages right now, dying of Ebola? He lit a cigarette, smoked it, and lit another one.

  8:40 p.m.

  Nadia Wauquier was sitting in the Library, opposite the entry door to the Hot Lab, when she saw the door open a crack. Augustine Goba put his face up to the crack—he was wearing full PPE. “I think I have a positive,” Goba called through his breathing mask, “but I can’t tell.”

  Nadia went to the entry and suited up as fast as she could. Two minutes later she was dressed in full PPE and huddled with Goba over a piece of equipment called a gel box. Inside the box they could see a pattern of glowing green bands against a dark background. The pattern was the fingerprint of something in Mamie Lebbie’s blood. Wauquier stared at the pattern. She couldn’t tell if this was Ebola or not.

  “Let’s contact Kristian Andersen,” Goba said to her. Andersen was a member of Pardis Sabeti’s War Room Team, and he had brought the equipment to Kenema. There was no time to lose, no time to make an exit from the Hot Lab. Wauquier unzipped her suit, took her cellphone out of her pocket, and took a picture of the image. She opened up the email on her phone. “Hello,” she typed. “We are in the Lab and have a question.” She attached the photo and hit send, and waited. There was no reply. It was Sunday afternoon of Memorial Day weekend in the United States.

  WAR ROOM

  CAMBRIDGE, MASSACHUSETTS

  4:55 p.m., Sunday, May 25

  Kristian Andersen and his wife had spent the day hiking in the White Mountains of New Hampshire. They returned home shortly before five o’clock. He puttered around their apartment for a while, and at 5:30 he checked his email and saw the message from Nadia Wauquier. He looked at the photograph of green bands, which she’d taken forty minutes earlier in the Hot Lab. He thought it could be Ebola, but he wasn’t sure exactly what he was looking at. This could be nothing. Or it could be a huge Ebola fire that was burning invisibly in Sierra Leone. Alarmed, Andersen sent Wauquier a reply asking for more information.

  Meanwhile, Nadia had hurried out of the Hot Lab and gone into her container lab. There, her PCR machine was coming up with a new set of results on Mamie Lebbie’s blood and the seven other blood samples taken from patients in the wards of the Kenema hospital. Once again, there were three positives, including the woman in the rural clinic.

  Nadia felt a wave of dismay and embarrassment when she saw the second set of results with three Ebola positives. This was not a false result, it really was Ebola. And it was in the hospital. There were two patients in the Kenema hospital with Ebola disease. Kenema Government Hospital was already going hot.

  She felt awful. She was a scientist. She was supposed to be a rational person. Yet she had rejected these Ebola positives the first time she had seen them. Her machine had been accurate. It had been screaming Ebola at her, but the mind doesn’t see what it doesn’t want to see.

  Nadia walked outside her container and found Humarr Khan, still sitting on the step in the alley, in darkness. He stood up when he saw her. “So?”

  “Your day is about to get worse.”

  “What—we have to redo the test again?”

  “No.” The woman in the upcountry clinic, Mamie Lebbie, really did have Ebola. And two more people had it, and they were inside the hospital.

  “Oh my God.” Khan sat down abruptly on the step.

  * * *

  —

  At that moment, Pardis Sabeti was sitting at the dining table in her apartment in Boston’s Back Bay, doing some work. Her pet rat was asleep in her lap. Her phone rang. It was Kristian Andersen, saying that he thought Ebola had gotten to Sierra Leone.

  Thoughts flashed through her mind. There’s never just one case of Ebola. It meant there was an outbreak happening. Invisible. Of unknown extent. It could be huge. Humarr Khan was in trouble. The Kenema hospital was in trouble. Sierra Leone was in trouble.

  She called a meeting of the Ebola War Room team, to start in half an hour. Then she placed her rat on the floor, went to the refrigerator, and took out a carrot and piece of celery, and chopped them up, and placed little piles of the chopped vegetables at spots around the apartment, so the rat could have a treasure hunt while she was out. Then she put on a pair of roller blades and a helmet, and skated down Commonwealth Avenue and across the Massachusetts Avenue Bridge to Kendall Square, and carried her skates up to the Ebola War Room, on the sixth floor of the Broad Institute.

  The War Room was a large room with whiteboard walls, which were forever covered with cryptic multicolored scribbles made by scientists writing with marker pens, a table made of blond wood, and a wall of windows that looked out on East Cambridge. About
ten people had gathered around the table, scientists and post-docs from MIT, Harvard, and the Broad Institute. “Right now, Ebola is only a single blip on the radar screen of Sierra Leone,” Sabeti said to the group. “It’s only one confirmed case, but it means this is an outbreak. I dread what Humarr Khan and his people are facing.”

  Sabeti drew up a plan of action. The machines at the Broad Institute could read the genetic code of the Ebola that was hitting Sierra Leone and Humarr Khan’s hospital. She knew that the virus’s code was changing as the virus moved through human bodies. Mutations would be accumulating in the code of this Ebola as the virus amplified itself in human bodies. Just how different would the virus be by now? Was this West African Ebola starting to mutate into something different from classic Zaire Ebola? Something more contagious? Something harder to treat?

  Sabeti and her team made plans to begin reading the genome of the virus as soon as possible. All the experimental drugs, experimental vaccines, and diagnostic tests for Ebola depended critically on the virus’s genetic code. Could Ebola be evolving away from the tests used to identify it? Could the West African Ebola be turning into some kind of Ebola that not even the untested experimental drugs could possibly stop? Where had the virus come from? Had the outbreak started with just one person, the little boy? Or had the outbreak begun in different people at different times and in different places? Was Ebola attacking the human population from different starting points? The answers to these questions concerned every person on earth.

  The War Room Team conceived a plan to obtain samples of blood from the people known to be infected with Ebola. They would read the genomes of whatever Ebola they could find in the patients’ blood.

  The virus was not a single thing but a swarm of particles. The swarm was moving through people and growing in size, and it could be mutating, changing its character as it grew. By looking at a few genomes of Ebola, the scientists hoped to make an image of the whole virus, which could be conceived of as a life form visible in four dimensions, as vast amounts of code flowing through space and time. To see the genome, they needed blood.