EIGHT

The Samaritans

IN LATE JULY, RANDY SCHOEPP of the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) took a rare few hours away from the diagnostics clinic he ran outside Monrovia to visit a new facility on the other side of town. It was a new Ebola treatment center, built at an existing hospital in Paynesville City, a major suburb along a bustling highway. The hospital itself had been maintained by Eternal Love Winning Africa (ELWA), a Christian missionary organization, since 1965. Now, another missionary group, Samaritan’s Purse, had become the first nongovernmental organization (NGO) outside of Médecins Sans Frontières (MSF) to open an Ebola treatment center. The facility would be called ELWA 2.

Schoepp was impressed with the new treatment center. For Liberia, still struggling to build its medical capabilities, it looked relatively modern, with as many protections for doctors and nurses as one could reasonably expect in a field hospital. The unit had forty beds, making it one of the larger facilities in Liberia at the time; half were reserved for confirmed Ebola cases, the other half for suspected cases.

A bright-eyed young Samaritan’s Purse doctor with closely cropped red hair named Kent Brantly guided Schoepp and a few other Army doctors around the building, showing them the new shower facilities that would decontaminate anyone walking from an isolation ward back into a clean zone. Brantly asked one of his colleagues, a Liberian nurse, to demonstrate the process of donning and doffing a protective suit; he was clearly proud, eager to show off the skill of both the American missionaries and the Liberian nurses and technicians who would staff the ward. Brantly asked what Schoepp thought, a sign of respect from one young doctor to an older, more experienced expert. Schoepp could not help being struck by his enthusiasm.

But something else struck Schoepp at the same time: Brantly didn’t look terribly well. Brantly had apologized when he refused to shake Schoepp’s hand when they first met, explaining he was a little under the weather. Neither the refusal nor Brantly feeling a little ill was odd. Almost no one was making physical contact amid the heightened tensions of the outbreak, and almost every Westerner making a first visit to West Africa would experience some kind of symptoms, whether a headache or an upset stomach. Schoepp thought nothing of it as he stood shoulder to shoulder with Brantly, watching the donning and doffing demonstration.

Back at the HIV diagnostics clinic a few days later, though, a new blood sample crossed Schoepp’s desk. It was labeled Tamba Snell, a name he recognized, one he had seen before, and one that was obviously fake. That meant the sample probably came from an employee of a nongovernmental organization; NGOs had a habit of labeling their employees’ blood samples with aliases, both to protect their privacy and to avoid the stigma of even being tested for Ebola in the first place. Schoepp thought back to the day before, when he had stood so close to Brantly, well inside the three-foot buffer zone recommended by health officials.

Then another sample crossed Schoepp’s desk, another alias, Nancy Johnson. Both came back positive. He asked his sources for the real identities of Tamba Snell and Nancy Johnson. The answers: two American missionaries working at the ELWA 2 hospital. One was named Kent Brantly.

A chill went up Schoepp’s spine. The fact that they stood so close together now meant that the Army doctor and the rest of his team were possible contacts, too. They spent the next three weeks testing their own temperatures at least twice a day, monitoring themselves for signs of the virus. Many times, one member of the diagnostics team would catch another with a thermometer. They exchanged knowing, fearful looks: You okay? Should I be worried? Every slight twinge or minor headache sent paranoid thoughts of Ebola racing through their heads.

Brantly was just thirty-three years old when Ebola came to Liberia. A deeply religious man, he had studied at Abilene Christian University in Texas, where he hoped to become a missionary. During his college years, he went on a mission trip providing care to poor children in Central America; it was a life-changing experience, one that convinced him that medical missionary work was the channel through which he would serve God. He earned his medical degree from Indiana University in 2009, then trained at John Peter Smith Hospital in Fort Worth, Texas, where he worked in a program for doctors who would practice in rural communities or in the developing world.

Only months after finishing his residency, Brantly, his wife Amber, and their two children had moved to Liberia, in October 2013, volunteering with Samaritan’s Purse, an organization founded by the evangelist Franklin Graham. Their small home, covered by a thin tin roof, faced the Atlantic Ocean. He quickly built a reputation at the ELWA 2 facility as a man of deep compassion: When it became clear that any of the sick patients wouldn’t survive, Brantly, clad in head-to-toe protective gear, would hold their hands, pray with them and sing to them.1

At the ELWA 2 hospital, Brantly met Nancy Writebol and her husband David, volunteers for another Christian ministry, Serving in Mission, the parent nonprofit that operated the ELWA hospital. David’s job was to keep the facility running, to keep the lights on and the generators pumping. Nancy was a clinical nurse associate, given the critical tasks of ensuring that doctors and nurses were properly suited in personal protection equipment before entering the isolation wards, then spraying them down with chlorine when they came out.

It was a relatively low-risk, though crucial, assignment; a line of tape on the floor of the shower area separated Writebol, dressed in gloves and a disposable apron, from doctors and nurses in full-body suits. Writebol would also take the temperatures of family members of infected patients, though none of them showed any signs of infection.

On July 22, her fifty-ninth birthday, Nancy Writebol came down with a fever, a symptom she knew well. A few months before, Writebol had contracted malaria, and now she thought the disease had returned. She asked a Serving in Mission doctor for a malaria test, which came back positive. Writebol returned to the small home she shared with David, where she had malaria drugs in the bathroom. All she needed, she thought, was some medicine and a few days’ rest.

But her symptoms kept getting worse. The fever didn’t break, and soon she developed a dull, intensifying headache. On Saturday, the same doctor who had given Writebol her malaria test stopped by their house. The doctor didn’t want to frighten anyone: “We’re just going to do the Ebola test, to relieve everyone,” she told Writebol. The doctor and David left for an all-staff meeting at the hospital, taking her blood sample with them. Writebol lay down for a nap.

A few hours later, once the samples had made their way to Schoepp’s lab, Lance Plyler, Brantly’s boss, got a text message from Schoepp’s team: “I am very sad to inform you that Tamba Snell is positive,” the message read. A short time later, Writebol’s sample—labeled Nancy Johnson—came back positive, too.2

David returned to their house. He stood outside the door: “Nancy, I have something to tell you,” he said. “Nancy, Kent has Ebola. And so do you.”³

The doctors who had accompanied David back to his home, to give his wife such terrible news, were beside themselves. “We are so sorry, Nancy. We are so sorry,” she later recalled them repeating, over and over.

Writebol was painfully aware of her odds. In the weeks since the ELWA facility had opened, she had watched forty patients enter the Ebola ward—the twenty beds for suspected cases quickly became twenty more beds for confirmed cases, and even then they had to turn potential cases away. Just one of those forty patients had survived. When the first two patients arrived on June 11, one, an older man, had not even survived the ambulance ride.⁴

In the weeks that followed, Writebol went over her time at the ELWA facility, trying to recall a moment when she might have come into contact with someone who was infected. Another technician who sprayed down doctors and nurses coming out of the isolation wards, a Liberian, had been infected a few days earlier in his community; he had come to work while showing early symptoms, but even then Writebol could not recall physically touching her colleague. She never figured out the moment at which she could have contracted the virus.

It mattered less how they were infected than how they would be treated. Plyler began making every phone call he could—to the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Canada’s Public Health Agency. He learned about more than a dozen possible treatments, with names like T705, rNAPc2, TKM-Ebola, and ZMapp. None had been tested on humans, though ZMapp had worked to cure monkeys infected with Ebola.

Plyler called Larry Zeitlin, the president of Mapp Pharmaceuticals, to beg for a dose. The only treatment course that was anywhere near the ELWA facility, though, was in the freezer in Kailahun, Sierra Leone, where at the same time Sheik Umar Khan lay dying. Brantly and Writebol both said they would opt for that drug, if it was available. Plyler and Zeitlin made contact with Gary Kobinger, of Canada’s Public Health Agency, to try to get the drug to the nearest airstrip, across the border in Foya, Liberia.5

The U.S. embassy in Monrovia sent Lisa Hensley, a microbiologist at USAMRIID who had spent her career looking for possible drugs to treat hemorrhagic fevers like Ebola, to Foya by helicopter to pick up the sample. She was accompanied by a U.S. marine—just a precaution, they were told. After flying through thick fog and pelting rain, they discovered that the doses of ZMapp had already left aboard a flight chartered by Samaritan’s Purse. The helo heaved back into the sky to return them to Monrovia.⁶

The three-dose course of ZMapp arrived at the ELWA 2 hospital in a Styrofoam cooler. Kobinger and others had been clear with Plyler: there is only enough medicine to treat one patient, they told him. The drug acts like a boxer fighting a particularly resolute opponent. One dose, or one punch, would knock the disease down, but it required two more punches to knock the disease out. Whatever he did, Plyler was not to split the doses between both patients.⁷

Plyler drove to Brantly’s small home, where he could speak to him through the window. The young doctor was doing better than expected, hovering in stable condition. He expected to be evacuated to the United States within just a few days. Together, they decided Writebol should get the treatment. Brantly called Writebol and urged her to take the drug.

Plyler jumped back into the car, drove the short distance to Writebol’s home, and handed the drug to Dr. Debbie Eisenhunt, one of ten doctors and nurses attending to the two Americans around the clock. Eisenhunt placed the first dose under Writebol’s arm, where it would thaw slowly; too fast and the serum could be destabilized.

Just hours later, on July 31, Brantly began to spiral. He looked visibly worse, sweating, groaning in pain. Plyler called Brantly’s wife, Amber, and Franklin Graham, to let them know. And he began to consider doing exactly what he had been told not to do—splitting the doses. Plyler unpacked the second dose and began to thaw it. Plyler closed his eyes and bowed his head: “God,” he prayed, “he cannot die.”

Plyler returned once again to Writebol’s house, where Eisenhunt retrieved the now-thawed first dose from under Writebol’s arm. They disinfected it, then wrapped it in a plastic bag, where it rode next to Plyler on the short trip back to Brantly’s home. There, he handed the vial to another physician, Dr. Linda Mobula, who inserted the drug into an IV bag dripping into Brantly’s arm. Plyler sat vigil outside Brantly’s home as the first drops of ZMapp filtered down into Brantly’s vein.8

Within half an hour, as the drug coursed through Brantly’s bloodstream, he began to shake, a tremor at first, then uncontrollably. It was the first hint that ZMapp was having an effect. After an hour of shaking, Brantly seemed to calm. Miraculously, it seemed, his fever broke, his temperature began to return to normal and his breathing, once laborious, steadied. Even the rash on Brantly’s chest seemed to fade. Doctors hooked up a new bag, this one a blood transfusion from a fourteen-year-old boy who had survived Ebola, and whose blood would carry antibodies that would give Brantly’s immune system another weapon against the disease.

The following morning, Brantly stood up and walked to the bathroom. A day before, he hadn’t been strong enough to stand.⁹

Writebol was not as lucky. Her first dose, the second in the course, administered beginning August 1, did not show the same instant effects it had on Brantly. In fact, she began to develop an itch on her hands, a possible sign of an allergic reaction. Her doctors dialed back the amount of serum dripping into her veins, which seemed to ease the discomfort.¹⁰ She, too, got blood transfusions, though none with Ebola antibodies—none of the Ebola survivors matched her blood type.

Back in the United States, the White House and the State Department scrambled to find a way to get the two Americans home. They identified one company, called Phoenix Air Group, that could do the job. The company, based in Cartersville, Georgia, had a single plane that could fly a patient at Biosecurity Level 4, the most secure environment. The “air ambulance” held a sealed room behind the cockpit, which was kept at lower air pressure than the rest of the plane. This ensured that any leaks would suck air into the compartment, rather than pushing air into the cockpit.

But even with the proper equipment to transport the two patients, there were problems. The air ambulance had taken off for Liberia on July 30, the day before Brantly received his first dose of ZMapp. It had to turn back because of a pressurization problem.11

Finally, on the morning of August 2, Brantly walked onto the plane under his own power. It lifted off, headed back to Atlanta. After it landed at about 11:20 a.m. local time, news helicopters captured video of a man in full personal protection equipment climbing out of an ambulance and walking slowly toward the open doors of Emory University Hospital, where an isolation ward waited. He was helped by another person in full protective gear. Kent Brantly was home.

Now, it was Writebol’s turn. The Phoenix air ambulance lifted off once again, bound back across the Atlantic.

But the second American was struggling. She had received two doses of the three-dose course, though she hadn’t experienced the same rebound as Brantly. Doctors had trouble finding a vein to keep her IV in; they eventually put an IV directly into the bone, which caused her terrible pain.¹²

Just hours before she would take off for Atlanta, Writebol made a point of asking for her favorite Liberian dish, a potato soup. She wasn’t sure she would ever have the chance to try it again; she didn’t think she could survive the ten-hour flight stateside.¹³ Dressed in full protection equipment, she was loaded onto a luggage conveyor belt to be placed in the level-4 biocontainment suite on the plane. One of her doctors put his hands on her mask and brought his face close: “Nancy,” he told her, “we’re taking you home.”

On August 4, Writebol arrived at Emory too. Brantly could see her through the window of their adjoining isolation units. He tried to wave, but she was too delirious to see him.

But with constant supervision in a world-class medical facility, both patients quickly improved. A new dose of ZMapp had arrived from Kentucky BioProcessing, the facility that made the experimental drug using tobacco plants, and both Brantly and Writebol completed their treatment courses. They discovered that small encouragements mattered. The day a doctor told her she had turned a corner, Writebol willed herself, for the first time in a week, to stand up, go to the bathroom and take a shower. Two weeks after entering Emory’s hospital, Kent Brantly walked out with a clean bill of health.

The happy ending to the stories of Kent Brantly and Nancy Writebol served as a rare positive moment, and a dire warning, to the global health community. On one hand, there was now evidence that the Ebola virus could be beaten. On the other, their illnesses had virtually shut down ELWA 2, one of the only hospitals in a city of a million residents where a highly contagious disease was only beginning to spread. Three other Liberian health-care workers at ELWA 2, including Writebol’s colleague, had also fallen ill. Two had died. Other NGOs saw the collapse as a particularly scary reminder of the ever-present danger. Two volunteers got sick at the first NGO other than Médecins Sans Frontières that tried to open an Ebola ward

In the United States, the sick Americans served as a catalyst for top disaster response experts, who began to realize the scale of the outbreak, and the warnings they had been hearing from Frieden, Fauci, and others.

“For us, the fact that Monrovia was now left without a net was much more concerning [than the two Americans falling ill],” said Jeremy Konyndyk, the head of the United States Agency for International Development (USAID) Office of Foreign Disaster Assistance. “From a containment of the disease perspective, what really started the alarm bells ringing was not that two Americans were sick, but that the one treatment option in Monrovia is collapsing, and there was nowhere for patients to go.”

The fact that Writebol and Brantly had survived, and that Dr. Sheik Umar Khan had not, set off another debate, one that put the World Health Organization (WHO) on the spot. WHO had been cautious about using the experimental ZMapp on a human without proper trials.

“Using an experimental vaccine on human beings in the middle of an outbreak in this case would not be ethical, feasible or wise,” one WHO official had told Science Magazine.14 But Writebol and Brantly were alive, and Khan was dead.

On August 6, WHO changed its stance. It would convene a panel of experts to consider the ethical ramifications of an experimental vaccine or treatment.

“The recent treatment of two health workers from Samaritan’s Purse with experimental medicine has raised questions about whether medicine that has never been tested and shown to be safe in people should be used in the outbreak and, given the extremely limited amount of medicine available, if it is used, who should receive it,” the agency wrote.¹⁵

But experimental drugs are just that, experimental. And the Centers for Disease Control and Prevention wanted to temper expectations as much as they could.

“The plain fact is that we don’t know whether [ZMapp] is helpful, harmful, or doesn’t have any impact,” CDC director Tom Frieden told a congressional committee on August 7. “And we’re unlikely to know from two or a handful of patients whether it works.”¹⁶

The message Frieden was sending was clear: The Ebola outbreak would not be stopped by a miracle drug, one that was both unproven and unlikely to be produced in mass quantities. The world needed to do more—and given that the WHO had proved so inept at accomplishing the job, the United States needed to take on a bigger role, maybe even the lead.

It was a message that would be delivered over the next month, repeatedly, as case counts mounted. By August 8, 2014, more than 1,700 total cases had been reported across Guinea, Liberia, and Sierra Leone. More than 950 people had already died. And the curve was beginning to bend upward.