Crisis in the Red Zone

by Richard Preston

  POTTER’S FIELD

  BROAD INSTITUTE, CAMBRIDGE

  9 a.m.

  An hour after Lisa Hensley took a snapshot of Kent Brantly, Pardis Sabeti got an email from Robert Garry, the Tulane microbiologist who had been gathering blood samples in Kenema for the Ebola genome study. Garry reported that Humarr Khan had Ebola. After reading the email, Sabeti walked into the Ebola War Room for a scheduled meeting. “Within thirty seconds,” Sabeti later recalled, “my face began to melt, and I just began hysterically crying, and then I looked up to see that everyone else was crying, too.”

  She called Robert Garry after the meeting. He was in his office in New Orleans. Sabeti and Garry had been making arrangements to set up an international conference call to discuss delivering experimental drugs and vaccines to African healthcare workers. Nurses were dying in Kenema—Mbalu Fonnie was dead, too—and Sabeti and Garry had been getting frantic as they tried to find some way to protect them from the virus. They decided that the first topic of the conference call would be to get medical help for Humarr Khan himself.

  KENEMA GOVERNMENT HOSPITAL

  Simultaneously—1 p.m.

  While Sabeti and Garry were talking on the phone, an ambulance pulled up in front of the morgue at the Kenema hospital. Two men wearing PPE emerged from the morgue carrying the body of Auntie Mbalu Fonnie, which was inside a white bag. They placed her in a casket, and loaded the casket into the ambulance. A few minutes later the ambulance arrived at the Kenema cemetery, which is situated in a brushy area on the outskirts of the city. It serves as the city’s potter’s field and was the only place where the Ebola dead were permitted to be buried.

  Many graves at the cemetery are unmarked. Grave markers, where they exist, are typically a wooden board or two pieces of wood fashioned into a cross. Mbalu Fonnie had always expected to lie next to her husband at the foundation of their house on the lower slopes of the Kambui Hills, a house he had built for Mbalu and himself. That would not be possible.

  The Ebola graves had been dug with haste. The bodies had been buried in shallow holes, with a mound of dirt on top. It had been raining hard, and the rains had washed out the mounds, revealing white body bags that poked out of the soil. Dogs or rats had torn open the bags and dragged out body parts. Ribs and arm bones were scattered in the weeds, and a human femur poked out of one of the mounds. Auntie’s mother, Kadie, was devastated by the sight. The family stood well back from Auntie’s grave as men wearing biohazard gear lowered her casket into a shallow hole, and covered it with earth.

  As he was riding home in a taxi after the funeral, Fonnie’s brother Mohamed Yillah began feeling warm. He knew this was his Ebola coming on, so he asked the taxi driver to stop at the hospital for a few minutes so he could have his blood drawn for an Ebola test. Afterward, at the family compound, Yillah told the children of the household not to touch him. He shut himself in his bedroom and asked family members to leave food for him outside the door.

  * * *

  —

  Later that afternoon, Humarr Khan’s ambulance arrived at the Ebola Treatment Center of Doctors Without Borders, in Kailahun, in the Kissi Teng Chiefdom of Sierra Leone. The treatment center was a cluster of tents sitting in a tract of forest on the outskirts of town. It was jammed with patients, and more were arriving every day. The staff at the camp was deeply stressed, hardly sleeping, and starting to get overwhelmed. When Khan arrived at the camp he was treated just like everyone else. Someone drew a sample of blood from his arm, and he was assigned to a tent in the red zone of the camp.

  An Ebola treatment center of Doctors Without Borders is the Ancient Rule updated with plastic. A hut made of palm fronds, placed apart from the village and stocked with water and food, was an ancient red zone. Smallpox victims were isolated in the red zone hut and were kept from having any contact with people in the village. There was no treatment for smallpox or for Ebola. You went into the red zone, you got food and water, and you either survived or you didn’t. After the survivors emerged from the hut, the hut was burned. This was on-site disposal of biohazardous corpses, the same thing the Doctors did when they buried infected corpses next to the camp.

  At a typical Ebola Treatment Center of Doctors Without Borders there were a dozen isolation tents made of white plastic, lined up in the center of the red zone. Each tent had cots for twenty patients. A plastic basin was placed next to each cot, which the patient could use for vomiting. There was a line of pit toilets—privies—near the tents. A disposable pad was placed on the cot if the patient had diarrhea and couldn’t move. The pad was supposed to be changed by a worker once a day. The patients were given plates of food and bottled water and soda. Bright orange plastic fences surrounded the red zone. There was a visitors’ area, where friends and family members could speak with patients across the fence. The visitors were required to stand at least six feet back from the fence. An Ebola patient could vomit suddenly, throwing infective droplets six feet through the air.

  Khan was placed in a sort of semi-private tent, which had only six cots in it, which was reserved for local medical workers who got infected. The part of the red zone that was next to the visitors’ area was covered with a metal shade roof that was supported by wooden posts. Khan sat on a plastic chair under the shade roof next to the visitors’ area, made some calls to government officials on his secret cellphone. He was very sparing in the use of his phone. There was no electricity in the red zone, and he had no way to recharge his phone when the battery ran down. His phone couldn’t be taken out of the red zone to be charged, since it was contaminated with Ebola particles.

  The sun went down, and Khan prayed. He didn’t feel very sick. He had only a mild fever and body aches. He still had a pretty good appetite. No vomiting or diarrhea. He had seen this before in many patients. The disease can start out like a minor bug, and you hardly know you have it.

  A few lights went on at the camp. A generator was humming somewhere, supplying power to two laboratory tents, which were stocked with blood-testing machines and freezers. A hundred feet away from Khan’s tent, inside a freezer, there was a cube made of white Styrofoam. The cube was about eighteen inches on a side, and it was dented, battered, and grimy, sealed with packing tape. Nobody at the camp knew what was inside the foam cube or who had left it in the freezer. The staff of the camp were much too busy to pay any attention to the cube. Inside were three small plastic bottles of frozen water with antibody proteins dissolved in it. They were Course No. 2 of ZMapp, and had cost $100,000 to manufacture.

  After he had finished his work at the camp, Gary Kobinger had left the drug in the freezer and returned to his lab in Canada. He had left the drug at the Kailahun camp because he wanted to test the stability of ZMapp in a tropical climate. He had no intention of offering the drug to anybody. ZMapp had never been inside a human body.

  KAILAHUN ETC

  Morning, Wednesday, July 23

  “Nobody’s telling me anything,” Khan complained to Simbirie Jalloh the next morning, speaking with her on his secret phone after his first night at the camp. He was wondering about plans for air evacuation. He told her that he had forgotten to bring his passport with him. She told him she’d take care of it. Khan spent much of the morning sitting in a plastic chair in the visitors’ area of the red zone, listening to rain clatter on a metal roof overhead.

  Simbirie called Michael Gbakie and asked him to search Khan’s house and bring his passport to him. “Please stay with Dr. Khan. He needs a friend with him,” she said. Michael found the passport in Khan’s bureau, and, hours later, he arrived at the visitors’ area of the camp. He told Khan he’d keep the passport nearby until Khan needed it—the passport couldn’t be brought into the red zone because it would get contaminated. Michael got a room in the town and stayed.

  As afternoon arrived in Sierra Leone, it was morning in the United States. Pardis Sabeti, in her office at Harvard, and Robert Garry, in his off
ice at Tulane, prepared to start an international teleconference call to discuss getting experimental drugs and vaccines for African healthcare workers. Khan’s need for an experimental drug was going to be their first order of business when the call started. Sabeti and Garry had looked into the dozen or so untested drugs that might be used to treat Khan. They had come to the conclusion that ZMapp would be the best option for him—if he could get flown to someplace where he could be offered the drug.

  Pardis Sabeti had been planning to lead off the call, but as the moment approached, she got afraid that her voice might break as she talked about Khan’s situation, so she asked Garry to speak first. Sabeti and Garry waited a few moments as Ebola experts in many places around the world began identifying themselves and joining the call. All of them knew Humarr Khan personally, and several of them were his close personal friends. The meeting went live.

  TELECONFERENCE

  9:30 a.m., Eastern Daylight Time, July 23

  Robert Garry began by saying that if Humarr Khan could be evacuated to a hospital in Europe, he should be offered experimental drugs. In Garry’s view, ZMapp was the best option. The drug had been successful in monkeys but had never been tested in a person. Khan was a medical doctor who had done trials of experimental drugs on human patients. Therefore he could weigh the risks of taking a drug like ZMapp, and could make an informed choice. “If there’s anybody who should get this drug, it should be Dr. Khan,” Garry said.

  Next, Pardis Sabeti spoke. She said that Khan was the perfect candidate for an experimental trial with ZMapp because of his understanding of Ebola, and because he was a national leader in Sierra Leone who could serve to inspire his country. But it was important to not just help Khan. “There has to be a sense of justice in how we proceed. It will be important to keep moving forward on treatments for everybody,” she said.

  The molecular biologist Erica Ollmann Saphire spoke. She was at home in San Diego, California, in a quiet corner of her apartment, while her husband organized breakfast for their children. Saphire was then running a laboratory at the Scripps Research Institute in La Jolla, where she was studying the molecular structure of Ebola and other viruses. She had collaborated with Khan on research into an anti-Lassa drug. She spoke forcefully, saying that ZMapp would be the best choice for Khan. She had been extremely impressed that the drug had saved eighteen monkeys with no failures, an extraordinary result by any measure.

  Khan’s friend Dan Bausch spoke. He was in Geneva, having just arrived there after working in the Kenema Ebola wards with Khan. He mentioned that there was a course of ZMapp sitting in a freezer in Geneva. The drug was earmarked for international health workers, but Bausch thought it would be appropriate to remove the drug from the freezer and fly it to the Doctors’ camp so that Khan could take it if he chose to. The drug had to be sent to Khan quickly, because he was getting sicker by the hour.

  Then Dr. Armand Sprecher, a leader of Doctors Without Borders in Brussels, dropped a bomb. “We can relax and not worry about the logistics of transport,” he said. “It’s not necessary.” Sprecher had recently learned there was another course of ZMapp sitting in a freezer right at Khan’s camp. Khan didn’t need to be flown anywhere.

  The news startled many of the people on the call. They had had no idea that a course of ZMapp was already at the camp. Pardis Sabeti, Robert Garry, Dan Bausch, and Erica Saphire felt a sense of relief when they heard that there was ZMapp at the camp with Khan. Garry got the impression that the drug would be given to Khan within hours. They felt the problem with Khan had been settled—he would get ZMapp at the camp. Nobody knew if it would help him, but it might give him a better chance of survival. Once the problem with Khan seemed to be solved, the meeting immediately moved on to the larger problem of getting experimental medicines delivered to all the African medical workers who were at risk from Ebola.

  KAILAHUN ETC

  2:30 p.m. local time

  Minutes after the conference call ended, Armand Sprecher phoned the clinical operations manager of the Kailahun camp, a registered nurse named Anja Wolz. Sprecher told Wolz about the conference call. He said that the experts had recommended that Khan be offered the ZMapp in the camp’s freezer. He told her he was personally in favor of it.

  Anja Wolz told Sprecher that she wasn’t comfortable about offering the drug to Khan. She had just learned about the drug in the freezer herself, and her reaction had been, “Oh, shit.”

  She told Sprecher that the idea of giving a totally untested experimental drug to just one patient in the camp made her feel very uneasy.

  “I’m not giving you advice,” Sprecher said to Wolz. “Dr. Khan is a friend of mine, but I know you will do the best thing.”

  She told Sprecher that she would consider the idea of giving ZMapp to Khan. “If you tell me this is okay, I’ll think about it,” she said to him.

  Right afterward, Anja Wolz called a meeting of the camp’s doctors and managers. Brussels, she said, was recommending that Humarr Khan be told about the drug in the freezer and be offered it. Among the doctors in the tent was a physician named Michel Van Herp. Van Herp and another doctor raised objections.

  The problem for them was fairness. Humarr Khan was a doctor. He was privileged. How was it fair to offer an experimental drug to a privileged doctor, when many other patients—children, poor people—would be dying of Ebola right next to the doctor while he was getting a treatment of extraordinary rarity that might save his life? All the other patients had no chance of getting an experimental drug.

  Doctors Without Borders adheres to an unyielding ethical principle known as “distributive justice.” The principle asserts that all human beings deserve equal access to the best available medical care. Under the principle of distributive justice, every person is entitled to the same care, whether they are rich or poor, powerful or weak. The principle requires that medical resources must be spread out equitably among all patients according to their needs. A homeless drug addict is entitled to the same medical care as a powerful government minister. In a disaster, if there is a shortage of doctors and medicines, the shortages must be spread out equitably among all patients—distributive justice does not play favorites in a disaster. For many of the European and American workers at the camp, if Khan was given ZMapp it would be an injustice and a breach of their most important ethical principle.

  Furthermore, the camp managers were worried that the drug could send Khan into allergic shock and kill him instantly. It had never been tested on a human. There was no oxygen at the camp—no way to sustain his breathing if he shocked out. As Joseph Fair put it later, “They basically said, ‘We’re not an ICU, we’re a fucking tent, and you’re asking us to stick ZMapp in him.’ ”

  If Khan died after getting the drug, Africans might believe the drug had killed him. Even if the drug did nothing and he died of Ebola, it might seem to Africans that the drug had killed him. There had been violence near the Doctors’ camp, and the camp’s managers feared that the local population could attack the camp if an African doctor died there after being given an experimental drug by white foreigners. There was a long history of violence by local people directed against Doctors Without Borders during Ebola outbreaks. Recently there had been rioting and threats of violence around a Doctors’ treatment center in Macenta, Guinea, not far from the Kailahun camp. If Khan died after being given the drug, Anja Wolz and the others felt that his death could endanger themselves and their patients, which could put their entire mission at risk.

  And what if the opposite happened, what if the drug saved Khan? This too would be a breach of ethics, because a privileged doctor would have been saved when no one else could be saved. There were only two possible outcomes of giving the drug to Khan, he would either die or survive. If he died it would endanger the mission. If he survived, and the drug appeared to have helped him, this would be a serious breach of the principles of Doctors Without Borders. Several people at the
camp said that if ZMapp was given to Khan it would be so unethical that they would consider resigning from the mission—they would quit and start working somewhere else, or would go home.

  They debated whether they should tell Khan about the drug in the freezer. If he knew about the drug he might ask for it. If they refused to give it to him and he died, then Africans would say that the white people had a special drug for themselves but they had refused to give it to a prominent African doctor and so he had died, and there could be violence directed at the camp. It seemed like the safest and most ethical action would be to keep Khan in the dark.

  Khan had no knowledge of this roiling debate.

  * * *

  —

  While the camp officials were discussing whether to offer the drug to Khan, Tim O’Dempsey, the WHO doctor who had been working in the Kenema wards with Khan, arrived at the camp in order to check up on Khan and offer him clinical care if he needed it. O’Dempsey was the director of humanitarian programs at the Liverpool School of Tropical Medicine, and is an internationally known expert in the delivery of medical care to populations in crisis. When he arrived at the camp he found that its leaders had closed themselves in a tent and were conducting a private meeting. After an hour, they invited him in and explained the situation.

  * * *

  —

  O’Dempsey knew next to nothing about ZMapp, but he knew Gary Kobinger, a co-inventor of the drug. O’Dempsey had a good cellphone, and he called Kobinger in Winnipeg, and reached him. He asked Kobinger if he himself would take ZMapp if he was in Khan’s position.