Crisis in the Red Zone

by Richard Preston

  She still needed to call Peter Jahrling to let him know that she’d had some exposures to Ebola and had decided not to return to the United States until the incubation period had passed. She worked late in the lab testing blood, and at ten o’clock she exited from the lab, got out of her space suit, and called Jahrling on her government phone.

  ARGUMENT

  MONROVIA AND FREDERICK

  10 p.m. West Africa time

  Rain was pouring, and Hensley couldn’t get a signal on her phone. Tropical storms were moving through, and communications had gone bad. Hoping for a better signal, she stepped outdoors to a rusty iron balcony that looked out over the roofs of the chimpanzee cages. It was pitch dark and pouring rain, but now she got a faint signal, and she reached Peter Jahrling in his office.

  Between the poor connection and the rain pounding on the metal roof of the chimp house, Hensley and Jahrling could barely hear each other. She told him she was going to fly on a helicopter to Foya the next morning to pick up a course of ZMapp for possible use in one of the two Americans sick with Ebola.

  “You’re doing what, Lisa?” Jahrling said loudly.

  Peter Jahrling almost blew a fuse. Hensley was flying around in helicopters with untested antibody drugs? And she could be infected with Ebola herself right now? “Lisa,” he said in a tense voice, “you need to come home. You should be getting your air tickets right now.”

  “I can’t leave. The situation is going to get worse.”

  “Exactly! It’s going to get worse! And you’re coming down with Ebola and you want to stay in Monrovia?” Jahrling couldn’t believe what he was hearing from his deputy. She could end up bleeding out in a tent. He told her that if there was any chance she was infected with Ebola, she needed to get herself back to the United States immediately. Because if she tested positive for Ebola in Africa, she would be barred from boarding an airplane out. She would be stuck. “If you were my daughter, Lisa, I would want you home,” he said.

  She reminded him that there was no plan for how to care for an Ebola patient once they reached the United States. “Until you guys have a plan in place for treatment of Ebola patients, I would rather not come home, Pete. Out of respect for my family and for you. I would never do anything to hurt my family.”

  Jahrling thought this was nonsense. She was an NIH scientist, she could go to the NIH hospital in Bethesda. It was, arguably, the best hospital in the world, and had a high-biocontainment ICU for a patient infected with a Level 4 virus.

  Yes, but if she stayed in Africa, she could continue testing blood, she said.

  “Testing a few samples of blood isn’t going to help!” he said, exasperated.

  The rain was pounding, and Hensley got loud. Testing blood saves lives, she said, because every time you can identify someone who has Ebola, you can isolate that person in a biocontainment ward, and so you can prevent that person from spreading the virus to others and creating more chains of transmission. There was no medical countermeasure to the virus, no modern medical defense. The only way to stop the virus was to stop people from giving it to other people, she said.

  Jahrling felt that the virus had gone so far out of control that just stopping a few people from spreading it wasn’t going to have any real effect on the epidemic. “You brought a water pistol to a forest fire.”

  “Pete, we can’t just pull out. What kind of a message are we sending if we just leave?”

  No amount of arguing was going to settle the matter. Jahrling was Hensley’s superior in the NIH chain of command. He could have given her a direct order to return home. If he did, she would either have to obey his order or resign from the NIH. He had been her boss for sixteen years, first at USAMRIID and now at the IRF. During that time he had seen her rise from being an inexperienced post-doc to becoming the chief of science at the IRF. In all those years, he had never given Hensley a direct order. Right now, Peter Jahrling feared that a key scientist was about to throw away her life testing blood. He was asking her to leave the field, but he wouldn’t command her to do so.

  After the call, Jahrling felt angry with Hensley. She’s gonna do whatever the hell she’s gonna do, he said to himself. Afterward, he went around the Integrated Research Facility complaining to people about how stubborn Lisa Hensley was.

  MONROVIA

  5 a.m., Tuesday, July 29

  Hours later, in the dark before dawn, heavy downpours were still falling on Monrovia. An Embassy car took Hensley to Payne Airfield, on the outskirts of the city, where a helicopter with U.N. markings stood motionless in the rain. The airport was socked in with thunderstorms, and conditions were too dangerous for flying. Lieutenant Colonel Bryan Wilson, USMC, was waiting for her. After asking her to take the mission, he had decided to accompany her—to provide peace of mind, he said. Hensley and Wilson sat in a waiting room by the tarmac, hoping for a break in the weather. A few miles away, at ELWA Hospital, Dr. Kent Brantly was awake and vomiting maroon-colored liquid into a basin. It was hemorrhage coming from the lining of his stomach. He would need another blood transfusion soon.

  FLIGHT

  MONROVIA–FOYA

  9:30 a.m., Tuesday, July 29

  Hensley and Lt. Col. Wilson waited by the tarmac for three hours while thunderstorms swept the airfield with rain and wind. The downpours eased, and they climbed on board the helicopter. It was an old Russian military chopper with U.N. markings, painted gray and generously equipped with dents. The pilots were breezy Ukrainians in possession of demotic English. Hensley and Wilson sat on benches facing each other, buckled seat harnesses across their chests, and put on hearing protectors. The helicopter lifted off.

  Almost immediately the flying conditions went bad. What had seemed to be a break in the storms had only been a lull. The downpours became crushing and opaque, but the pilots pressed onward, the helicopter leaning into walls of rain.

  There was a window by Hensley’s shoulder. When she turned and looked out, she could see almost nothing except moisture whipping across the glass, but now and then she caught a glimpse of a mountain ridge covered in jungle, slipping by below.

  At the moment, she didn’t know whether Dr. Humarr Khan was alive or dead. What was certain was that he couldn’t get a flight out, and Doctors Without Borders was not going to give him ZMapp. But the drug might help someone.

  She dozed off in her harness. After a while she woke up, and she noticed that the lieutenant colonel was awake. “I don’t know how you can sleep,” he said, seeming a little uneasy. If a Marine seemed uneasy, maybe there was something to be uneasy about. “We’ve been flying in near-zero visibility,” Lt. Col. Wilson remarked.

  In this epidemic, everybody was flying in near-zero visibility. Below the helicopter, lost in the rain, Ebola was maneuvering in secret. No drugs or vaccines were known to work against the virus. She was on her way to get one course of an experimental compound in an effort to save one human life.

  She sensed there would be consequences as a result of her choice to stay in Africa and go on this helicopter flight. She would deal with them later. The real question, for her, was how her actions would look to James when he was old enough to understand them. If she had left her mission and returned to the United States, James would find out some day. What would he think of her choice, when he was old enough to understand it? Viruses more powerful and dangerous than Ebola were going to emerge in the future, and medical people were going to have to deal with them. “If we don’t help, what message are we sending our children?” Hensley would later say. “Our children are going to inherit these problems, and people are dying. Part of the responsibility of a parent is to teach our children how to be responsible. We have to set the example for our staff, our families, and the patients in Africa.”

  Hensley’s helicopter descended into a brushy valley surrounded by the forested hills of Foya, Liberia. As the chopper touched down, she noticed U.N. soldiers we
aring combat vests and HEPA masks, and holding assault rifles. She and Lt. Col. Wilson got out of the helicopter and learned that the bush pilot from Samaritan’s Purse had landed there an hour before, and had already departed with the drug.

  They strapped themselves in, and the chopper carried them back to Monrovia. By the time they landed, the drug had already been delivered to Lance Plyler at ELWA Hospital. Hensley and Wilson stopped at a café in downtown Monrovia for a cup of coffee and a sandwich. She planned to proceed to ELWA Hospital immediately afterward. It was 1:15 in the afternoon.

  KAILAHUN ETC

  About 1:00 p.m.

  While Hensley and Wilson were sitting at the coffee shop in Monrovia, Michael Gbakie entered the Doctors’ camp in Kailahun to check on Humarr Khan. He walked through a zigzag of passages marked by plastic fences, and ended up in the visitors’ area adjacent to the red zone. Standing six feet back from the red zone fence, he faced Khan’s tent and called out, “Dr. Khan!”

  Nothing happened. He kept calling Khan’s name, waiting for Khan to come out, as he had always done in the past when Michael shouted to him. Minutes ticked by, while Michael got increasingly worried. There was something wrong. “I decided to go inside so I could make my own assessment,” he said later. Standing in the visitors’ area, he took out his cellphone and called a doctor at the camp, and asked that he be allowed to go into the red zone with a Doctors worker so that the two of them would check on Khan. The doctor told him this would not be possible.

  Michael was starting to get angry. He had the phone number of the minister of health of Sierra Leone, Miatta Kargbo, and he called her and told her about the situation. She, in turn, phoned Anja Wolz, the manager of the Kailahun camp, and told her to allow Michael to enter the red zone so that he could assess Khan’s condition.

  After the minister called her, Anja Wolz called Michael. By his account, she said, “What is the problem?”

  He was pissed. “I want you to allow me to dress and go in to see Dr. Khan. I have not seen him in the visitors’ area today.”

  “According to protocol we do not allow people to go in.”

  “I am with the Kenema Lassa program. I am very experienced with PPE.” He told Wolz that he was now going into the red zone with an IV kit of Ringer’s solution for Khan and nobody was going to stop him.

  Wolz relented.

  Michael went to the dressing area at the camp, where workers were issued cotton scrub suits, impermeable suits, and the rest of a full PPE kit. When somebody handed him a scrub suit, he saw the material was old, and it looked dirty to him. He got mad. “No. I won’t have this. I’m an infection prevention and control officer, and I don’t know where this scrub suit came from. I have my own scrub suit and boots.” He went to his vehicle and got the items, and returned to the dressing line. Then he dressed himself in PPE while a worker gave him instructions on the Doctors’ dressing procedures. Then he and a Doctors worker entered the red zone and began making their way toward Khan’s tent.

  ELWA HOSPITAL, MONROVIA

  1:55 p.m., Tuesday, July 29

  About the time Michael went into the red zone, an Embassy vehicle dropped Lisa Hensley at the offices of Samaritan’s Purse at ELWA Hospital. She climbed a stairway lined with breeze-blocks and found Lance Plyler sitting at his desk, staring at a dented, dirty cube of foam sitting on the floor, which was held together with packing tape. He had a look of panic on his face. “What do I do with this stuff?” he said. He didn’t seem to want to touch the cooler.

  “Do you want me to open it?” Hensley said.

  “Yeah. That would be great.”

  She peeled off the tape and lifted the lid. A swirl of ice fog tendrilled out. Sitting in a nest of dry ice at the center of the box were three small plastic bottles. They had screw caps, and the caps had been dipped in wax to seal them. This was Course No. 2 of ZMapp.

  Plyler stared at it. “What do I do with this stuff?”

  “Let’s call Larry Zeitlin,” Hensley said. She reached him at home in San Diego, where it was seven o’clock on a Tuesday morning. He was getting his five-year-old dressed while his wife looked after their newborn baby. Hensley handed her phone to Plyler.

  “What should I do with this drug?” Plyler asked Zeitlin.

  Larry Zeitlin couldn’t tell him what to do. As scientists involved with the drug’s development, he and Lisa Hensley were barred from giving any advice on whether or not to give the drug to a patient.

  Hensley could see Plyler’s struggle etched on his face.

  Lance Plyler was the lead physician in charge of Nancy Writebol and Kent Brantly. There was only one course of the drug, but there were two patients who needed it. Both were dying. Plyler would have to choose between the patients—offer the drug to one of them and let the other one die. The drug was unlicensed and untested and had never been introduced into a human body. It could kill a person in minutes, especially if the person was already dying. The best decision might be to put the patients in God’s hands and keep the drug in the cooler and not give it to anyone.

  “There is no right decision and no wrong decision,” Hensley said, trying to reassure him. She emphasized that she couldn’t guide him to a decision. However, if he did choose to give the drug to somebody, she said to him, he should follow a protocol laid out by the drug’s principal inventors, Gary Kobinger, Gene Olinger, and Larry Zeitlin. According to the protocol, the three doses must be given to one person. He must not split the drug between the two patients—not try to stretch it out. If he were to split the drug between two people, the drug wouldn’t help either of them and both patients could die.

  Furthermore, she told him, the drug should be given to the person who is less sick. If ZMapp was given to the sicker patient, it might have a positive effect but the person could still die, and then the drug would have been wasted. In other words, Lance Plyler was supposed to practice triage.

  Plyler seemed paralyzed by the weight of the decision. “What should I do with these if we don’t use it?” he asked.

  “I’ll get them back to Larry Zeitlin.” She put the lid back on the box, fitting it tightly so that the dry ice inside it wouldn’t melt. At about 2:30 p.m. she left Plyler alone in his office, staring at the box on the floor.

  KAILAHUN ETC

  2 p.m.

  Michael Gbakie and a worker from Doctors Without Borders arrived at the small tent where Khan and the other Kenema medical staff had been placed. They found Khan lying on his cot. There was mess all around him of vomitus and stool. His clothing was soaked and filthy, and the pad underneath him hadn’t been changed in a while. Michael was wearing goggles and a mask, and he was completely shrouded in hazmat material. “Dr. Khan,” he said through his mask. “It’s me, Michael.”

  Khan didn’t seem to recognize him.

  “It’s me, Michael,” he shouted.

  Khan picked up his head and looked at him.

  Michael helped him sit up, and then he took off all of his clothes, cleaned his body with disposable pads, got him dressed in fresh clothes, and put fresh pads under him. As Michael was dressing him, Khan spoke for the first time, and asked for a soft drink. Michael helped him sip it. “I want to rest a little bit,” Khan said.

  He got Khan adjusted and lying down. He decided to exit and try to find Khan’s houseman, Peter Kaima, who had stayed with Khan. He went through a decon line, got sprayed with bleach, and workers helped him remove his gear. He found Peter Kaima just outside the camp. He talked with Kaima for a little while, and then went back to the visitors’ area in order to call out to Khan’s tent and ask how he was doing.

  Meanwhile, Mohamed Yillah, the brother of Mbalu Fonnie, was lying in a cot next to Khan. Yillah had been giving care to Khan, but he hadn’t had enough strength to get out of his cot and help clean Khan. Now he did get out of his cot. He thought Khan needed some fresh air. He got Khan sitting up, then lifted
his feet out of the cot and placed his feet on the plastic floor of the tent. Then Yillah got his arms around Khan and lifted him out of the cot. Carrying Khan in his arms the way you would carry a baby, Yillah walked out of the tent. There is no medical explanation for how a man in late-stage Ebola disease could pick up another man and carry him.

  Staggering, going step by step, Yillah carried Khan to the visitors’ area, then laid him down on a soft plastic mat on the ground near the fence. Then Yillah collapsed in a chair next to Khan. After a while, though, Yillah managed to get himself out of the chair, and he went back into the tent and lay down on his cot.

  Shortly afterward, Michael entered the visitors’ area, and he found Khan lying on the mat by the fence. Khan was gasping for breath. “Dr. Khan?”

  Khan didn’t respond.

  “Dr. Khan!”

  Khan turned his head. “Michael….” He seemed to swallow the word Michael down his throat, and nothing more came out, and his breathing stopped.

  “Dr. Khan is dead!” he shouted.

  KAILAHUN ETC

  About 3 p.m.

  At the moment Michael shouted, “Dr. Khan is dead,” Khan’s older brother Sahid, who was in Philadelphia, was talking on the phone with Peter Kaima, who was standing just outside the camp. Sahid heard a series of cries erupt in the background. “What is happening?” he asked Kaima.

  “Doctor has left us,” Kaima answered, and started to cry.

  That was when Sahid Khan realized that he had just heard the moment of his brother’s death, over an open phone line.

  Mohamed Yillah, who was lying in his cot in the tent, having just carried Khan into the open air, felt a wave of regret. He had left Dr. Khan to die alone. He hadn’t realized Khan was dying, or he would have stayed with him. At that moment, Yillah wanted more than anything else to be able to rise up from his bed and have a last sight of Khan, but he found himself utterly unable to move.