Crisis in the Red Zone

by Richard Preston

  Minutes afterward, Pardis Sabeti learned that Khan was dead, and she wept uncontrollably. Much later, she reflected on Khan’s death. “In the fight with infectious disease we see death all the time, and we wonder why it happens. We’re all trying to understand our place in the universe and why we’re here. Khan’s death left me with a feeling that we just have to do more, and that men like him can’t be lost in vain.”

  KAILAHUN ETC

  About 4 p.m.

  As the afternoon wore on, Auntie’s brother Yillah, who was lying in his cot unable to move, started getting angry. It distressed him that patients in the Kailahun camp weren’t getting IV hydration. He felt that he had just seen the result of that policy, in Khan’s death. You need fluid to replace what you are losing. A person who has no fluid is just waiting to die. The Kenema medical staff still alive in the tent were himself, the lab technician Mohamed Fullah, and Nurse Alice Kovoma.

  Yillah wasn’t going to take any more of this. His phone battery still had a charge. He called Simbirie Jalloh in Kenema and asked her to send ambulances to the Doctors’ camp and bring all the surviving Kenema health workers back to the Kenema hospital. “I want to go back to Kenema to die,” he said to her.

  Night was coming on, but she promised him that ambulances would leave at dawn the next morning to pick up him and the other Kenema health workers. She had already dispatched one ambulance to pick up Khan’s body. Early that evening, Kenema lab technician Fullah died in his cot; afterward there were only two Kenema workers left alive in the tent—Mohamed Yillah and Alice Kovoma.

  Camp workers picked up Khan’s body on a stretcher and carried it to the morgue tent. Shortly after sunset, workers delivered Khan’s body, inside the bags, to Michael Gbakie. He and other workers, all of them wearing PPE, loaded the body into the back of the ambulance, and Michael and a driver set out for Kenema.

  The driver went fast on the rugged road. Michael bounced in the passenger seat, staring through the windshield. There was nothing to see: Clouds covered the sky, and there were no lights in the countryside because there was no electric power in that part of Sierra Leone. He thought, If a doctor we were all listening to has died of Ebola, then what will be our fate? What will be my fate? The Kambui Hills appeared, their outlines barely visible against the sky, and the sparse lights of the city drew near.

  HIDDEN PATH

  ELWA HOSPITAL

  6 a.m., Wednesday, July 30

  Dr. Lance Plyler was lying in bed in the dark, looking at the white foam cooler. It sat on the floor next to his bed, a ghostly enigma. The drug inside the cooler could kill Kent or Nancy. Or it could rescue one of them. Or it could do nothing.

  Dawn came, and Plyler opened his eyes. The cooler was sitting there. He hadn’t been able to move it or even touch it since he’d left it next to his bed. He got up and went into the kitchen.

  He was sharing the house with other staff members of Samaritan’s Purse. He made coffee for everybody, and went back to bed with a cup. Sipping coffee, he took up his Bible, read Psalms, and prayed. The shipment of TKM-Ebola, from Tekmira Pharmaceuticals, had been lost in transit and hadn’t reached Monrovia. The three bottles of ZMapp were the only option now. There was enough of the drug for only one person.

  Kent Brantly was a good friend of his. If he offered the drug to Kent and it killed him, he would have killed a friend. Or the drug might save Kent’s life. But if he offered the drug to Kent, then he would have to deny the drug to Nancy Writebol, and she would then almost certainly die. Nancy deserved the same love and justice that Kent deserved. But Nancy was sicker than Kent, closer to death. Plyler knew the protocol: He should offer the drug to Kent, who wasn’t as sick as Nancy, and he should let Nancy die.

  He couldn’t forget his Hippocratic oath: “First, do no harm.” Every possible choice he could make had the potential to cause deadly harm to at least one person and possibly to two people. How could he make a decision if every decision could cause deadly harm? He prayed for guidance, hoping to receive a sense of what he should do. He felt God near him, but it seemed as though God was guiding him only one step at a time.

  Lisa Hensley couldn’t advise him what to do. She had participated in the drug’s development. And in any case she wasn’t a physician. He was the physician. Yet he wanted to talk with her again, not on the phone, face-to-face. He texted her, asking her to come to the hospital.

  ELWA HOSPITAL

  1:30 p.m., Wednesday, July 30

  In early afternoon, she arrived in an Embassy car. She found Plyler alone in his office at the top of the breeze-block stairs, sitting at his desk.

  Hensley sat down in a chair facing Plyler.

  He was in agony. “I don’t know what to do. I just want to save my friend. What should I do?”

  “I can’t tell you what to do.”

  “Would you take the antibodies yourself, Lisa?”

  She had to pause and think before she answered. If she told him she would take ZMapp for herself, would this be a recommendation that he should give the drug to a patient? You don’t want to cross that bright line, the ethical line, she told herself. After a long pause, she said, “If it was me, I would take them.” After the words came out she wondered if she’d said too much.

  “Lisa, I’m not trying to question your integrity, but I’m just going to shoot it to you straight. I know you have a conflict of interest. I know you want to help, but you’ve been developing this drug for years, and you have an interest in giving it to a person.” I have just met this woman, he thought. Can she go beyond her scientific endeavors and do the right thing? “I am begging you, please!” Plyler burst out. “If this was one of your own, a family member, would you give it to them?”

  They were staring at each other across his desk, eyes locked. She didn’t answer.

  He kept his eyes on her, watching her face for a clue that might reveal her emotions or her thinking. He saw her look away, and she seemed to focus her gaze on something that wasn’t in the room. Something private and painful, he thought. Momentarily he wondered if she had children. Then he remembered that she’d mentioned a child, a boy. He didn’t know anything about the boy.

  Excruciating moments passed. The moments got longer, and still Hensley didn’t speak. What would happen if I got Ebola, Mom? If the drug were given to a child with hemophilia, it could be unpredictable and dangerous.

  Finally she broke the silence. “Yes. I would give it to a child of mine.”

  Her simple answer after such a long silence convinced him that she was telling the truth. Even so, he sensed deep emotions in her that he couldn’t see or understand. There is something heavy on her heart, he thought.

  As he searched his own heart, Plyler still couldn’t see a path to a choice. He told her that he still didn’t know what to do.

  At this point, Hensley suggested that they set up a conference call with the three principal inventors of the drug—Gene Olinger, Larry Zeitlin, and Gary Kobinger. None of them answered their cellphones. Then she said to Plyler, “Let’s call my dad.” She explained that her father was a scientist who had run clinical trials of experimental antibody drugs on human subjects.

  Mike Hensley answered immediately. She switched her phone to speakerphone and placed it on Plyler’s desk, and they leaned in over the phone until their heads were almost touching.

  “Dad, would you give me ZMapp if I had Ebola?”

  Mike Hensley answered promptly: “Yes, I would give it to you, Lisa.” He had already spent a lot of time thinking about that.

  Larry Zeitlin called in.

  Plyler questioned Zeitlin: “Would you take ZMapp yourself?”

  Zeitlin had to think for a moment. After a pause, he said, “With the caveat that it would be ethically dubious for me to recommend ZMapp, I would take it myself.”

  Hensley said, “Larry, the issue is, would you give it to your child?
”

  Plyler was hunched over Hensley’s phone, waiting for an answer from Zeitlin.

  This is indeed the question, Zeitlin thought. He thought about his five-year-old daughter and his baby. At that moment he felt very unimportant and a long way from Africa. He took a breath. “Yes, I would give it to my child.”

  Afterward, Plyler decided to visit Kent Brantly to check on his condition and pray with him. He drove his pickup truck to Kent’s house and stood at the window and looked in. A doctor named Linda Mobula, dressed in PPE, was caring for him.

  Kent was lying motionless in bed. He was conscious and in excruciating pain. His eyes were bright red, his pulse was racing, and his breathing consisted of shallow, rapid panting. The rash now covered his body from head to toe. He had been given three blood transfusions to replace what he was losing in hemorrhages, and his diapers were getting soaked in fluids and blood. Kent didn’t think he had the strength to keep breathing for much longer. If he couldn’t breathe on his own he would die, because there was no oxygen or respiration equipment at the hospital.

  Lance and Kent shared scripture and talked briefly. The medevac jet was due to arrive in two days. Two days is a long time when you’re dying of Ebola. Kent thought there was a chance he might be able to keep his breathing going for about forty-eight hours, long enough to get on the jet. As soon as he was on board he would be put on a respirator and given artificial life support. The equipment might keep him alive for the duration of the flight, and if he made it alive to the hospital in Atlanta, he would get advanced care. Nancy, on the other hand, couldn’t possibly survive long enough to make it onto the jet. “Give the drug to Nancy,” Kent said.

  Lance left without telling Kent what he would do.

  ELWA HOSPITAL

  6:30 a.m., Thursday, July 31

  The next morning, at break of day, Lance Plyler was sitting in his bed, drinking coffee and looking at the foam cooler. The Atlantic surf beat on the sand outside his window. He hadn’t been able to touch the cooler since he’d put it next to his bed. He took his Bible out of his shoulder bag and opened it. The pages were limp and fragile, darkened with sweat from his hands, and marked everywhere with pen and pencil. He turned to the Book of Esther.

  In the story, young Queen Esther, a Jew, is married to the king of Persia. Her uncle, Mordecai, discovers a plot in the king’s court to have all the Jews of Persia killed. Mordecai urges Esther to warn the king of the plot and thereby try to save the Jews of Persia. He says to Esther, “Yet who knows whether you have been called to the kingdom for such a time as this.” At risk of her life, Esther warns the king and thereby saves the Jews.

  It seemed to Dr. Lance Plyler that he might have been called to the kingdom for such a time as this. Unlike Esther, though, he couldn’t save everyone with his choice. He would have to make a choice; there was no course of action that didn’t require a choice. One choice would be to do nothing—not use the drug—and let God choose who would live or die. But he felt that, as with Esther, God seemed to be giving him the responsibility of choice. Kent had urged him to give the drug to Nancy. But if he, Lance Plyler, defied the rules of triage and gave it to Nancy, she could die anyway, and he would be abandoning Kent. He closed the Bible.

  He wondered if he could split the drug between the two patients after all. This would be a high-risk maneuver. If he gave one dose to Nancy and one dose to Kent, both patients would need to be flown quickly to Atlanta, no delays, no hang-ups. And there would have to be more ZMapp in Atlanta waiting for them. If anything went wrong, both patients would die.

  Nancy Writebol’s house was just around the corner. Later in the morning, Plyler ended up standing at Writebol’s window, looking at her. She had end-stage Ebola disease, and was bleeding into her skin and hemorrhaging from her intestinal tract. She was much older than Kent, less physically fit, and it was clear she could die at any moment. As Plyler looked in through the window, his compassion for her blew away the rules of triage. If he didn’t do something, she was going to die. He decided, finally, to give the drug to her. He had made his choice.

  Later that morning, Plyler left the cooler on Nancy’s porch with instructions for Nancy’s attending physician, Dr. Deborah Eisenhut: She was to thaw one of the three bottles and administer it to Nancy intravenously in saline solution. The foam cube sat unopened on the porch for several hours, while the staff prepared Nancy Writebol to become Experiment Number One.

  KENEMA GOVERNMENT HOSPITAL

  Noon, Thursday, July 31

  As the staff at Samaritan’s Purse was preparing to give ZMapp to Nancy Writebol, the funeral for Humarr Khan began at Kenema Government Hospital. A crowd of five hundred people had gathered in front of the children’s ward, where a white casket rested in a viewing area. This was the same place where the crowd had gathered holding candles and singing, hoping to ward off Wahab the Visioner’s prediction that an important doctor would die.

  After the service, a group of pallbearers, dressed in bio-hazmat suits, carried the casket to a patch of stony ground in front of the unfinished buildings of the new Lassa ward, not far from Khan’s smoking place. Gravediggers had started digging, but were having a hard time making progress. The rocks of Kenema are three billion years old, and they resist change. Hours passed while the gravediggers chipped and hacked at the ground. Finally the crowd dispersed, leaving the gravediggers alone with the casket, still digging. A rain shower moved through.

  * * *

  —

  Soon after Lance Plyler left the cooler on Nancy Writebol’s porch, Samaritan’s Purse sent out a worldwide press release announcing that they had given an experimental antibody drug to an American sick with Ebola. According to the press release, the drug had been provided by the National Institutes of Health and by Lisa Hensley, an NIH researcher.

  Minutes later, CNN picked up the release from Samaritan’s Purse and posted a story about it on its website. During the next hour, emails started arriving in Hensley’s inbox, coming from Ebola experts all over the world. They were surprised and upset, and they fired questions at her. Lisa, what did you just do?…You provided experimental antibodies to an American patient?…The antibodies came from the NIH?…Are you crazy?…Who authorized you to provide untested antibodies to a patient?

  Hensley was in her space suit in the lab and didn’t see the emails. In fact, the drug hadn’t yet been administered to Nancy Writebol. The director of the CDC, Dr. Tom Frieden, saw the news reports and called Dr. Anthony Fauci, the head of NIAID—the NIH institute that runs the Integrated Research Facility at Fort Detrick. Frieden was upset, and he asked Fauci what was going on in Africa with this NIH researcher and this NIH drug. Anthony Fauci was taken quite by surprise. It seems he hadn’t known anything about it. If an experimental, unlicensed, untested drug is supplied by the NIH and is provided to a patient by an NIH employee, any decision to give the drug to the patient must be handled by top-level administrators at the NIH and must be overseen and authorized by the Food and Drug Administration. It seemed that Lisa Hensley had broken all the rules. The leaders of the NIH knew next to nothing about her. She was a lower-level scientist who’d been working at the agency for only a few months. The heads of the NIH began asking, in effect, Who is this Lisa Hensley person and what the hell did she do? Whoever she was, she seemed to have gone rogue.

  Peter Jahrling’s immediate superior, an NIH administrator named Cliff Lane, came down on Jahrling and asked for details. Jahrling had to tell Lane that Hensley had flown on a helicopter to get the antibody drug and that she might be infected with Ebola. Jahrling apologized for not having informed senior management about this. Very suddenly, it looked like Jahrling was in trouble.

  Jahrling was told to issue a direct order to Hensley to return to the United States immediately, where she would face an investigation and very likely be fired. The investigation would start as soon as possible, even before she returned to the Unit
ed States. In a space of two hours, Hensley’s career went down in flames.

  ELWA HOSPITAL

  1 p.m.–6:50 p.m., Thursday, July 31

  Dr. Deborah Eisenhut tucked a bottle of frozen ZMapp, the first dose, into the bedding near Nancy Writebol’s arm, to let it thaw.

  While the bottle was thawing, Peter Jahrling called Lisa Hensley and ordered her home. The NIH had already started an investigation and wanted to see every electronic communication she had sent or received before and during her deployment in Africa—every text message, every email, and records of every phone call. Investigating officials wanted to know exactly where and how she had gotten the drug, what she had done with it, and where her authority for these actions had come from.

  Lance Plyler knew nothing about Lisa Hensley’s recall to the United States or the investigation into her actions: She decided not to tell him about it. Late in the day, Lance Plyler, having made the decision to give the drug to Nancy, got in his pickup truck and drove to Kent’s house to see how he was doing. He arrived at the house a few minutes before sunset. The rains had held off, and the sun was setting through incandescent clouds over the Atlantic. By the light of sunset, he looked through the window at Kent Brantly. What he saw terrified him.

  CRASH

  ELWA HOSPITAL, MONROVIA

  6:50 p.m., Thursday, July 31

  Kent Brantly’s face was a gray mask. His temperature was 104.7. He was breathing thirty times a minute, in shallow pants, and his blood oxygen was dangerously low. At times his breathing would slow down and almost come to a halt, and then he’d suck a lungful of air and resume panting. This is known as Cheyne-Stokes breathing, and it is a sign of imminent death. Lance Plyler had seen many people die, and he knew the look. So did Kent Brantly, who was trying to force himself to breathe. With no ventilators at the hospital, he would never make it through the night.