Crisis in the Red Zone

hemorrhages from other openings of the body, and it causes brain damage, coma, and death. Sister Beata didn’t waste any time trying to diagnose the woman’s malady. Her goal was to deliver the woman’s child and try to save two lives.

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After childbirth, any broken blood vessels in the uterus would quickly seal themselves through clotting, and any bleeding would stop. Ms. Ndobe’s bleeding intensified into an uncontrollable hemorrhage pooling on the metal surface of the table. Ms. Ndobe was bleeding out. As her blood spread across the table, her blood pressure fell, her heart began beating

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rinse her hands and arms. Hemorrhage during childbirth was a major cause of death in younger women in Africa. —

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She developed projectile vomiting, which is also called rocket vomiting, in which the stomach contracts violently and the vomitus is ejected up to two meters, or six feet, through the air. The vomitus would have ended up on

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vomitus had a normal appearance, but on the second day it came up streaked with blood, or it resembled red paint.

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The black vomit is a sign of a fatal case of yellow fever. It is a hemorrhage from the lining of the stomach, and it consists of granules or curds of blackened blood which have been partly digested by stomach acid. Black vomit has a characteristic “wet coffee grounds” appearance, in which the granules are mixed with a dark, watery fluid that resembles weak black coffee.

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As she got sicker, her stool changed into a black liquid. The liquid, known as melena, is hemorrhage coming from the linings of the intestines. The membranes that form the linings of the intestines had died and were now undergoing bacterial decomposition.

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space of the body is the soft tissue that lies between the skin and the muscles and fat. The third space can fill up with fluid or blood. Sister Beata’s facial expression changed, and her face settled into blank mask, seemingly without emotion, and with inflamed eyes. YAMBUKU CATHOLIC

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the viaticum to her, and tears of blood came from her eyes and ran down her cheeks. The fluid that came from her eyes would have been a mixture of tears and blood. The blood was hemorrhage coming from the wet membranes of her eyelids. Sister Beata’s blood had lost its ability to clot, and so it mixed into her tears the way dye spreads into water, and the red liquid ran down

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Then he dabbed his bloodstained handkerchief into his own eyes, one and then the other, wiping the tears from his eyes, and he put his handkerchief back in his pocket. Father Germain had infected himself with Sister Beata’s bloody tears, and he would be dead thirteen days later. Sister Beata died at sunrise on that Sunday morning, just at the moment when the palm swifts were flying out of the palms and beginning a new day.

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they hiccuped, they had nosebleeds, they became demented, and then, as the disease progressed, they expelled black blood from the anus. Then, for many of these patients, their fever went down and they started feeling better. This was a false dawn, which lasted for about forty-eight hours, and ended with a sudden collapse of blood pressure, known as a crash, followed by death. As the patients crashed and died, they had tremors and shaking at the point of death, and some went into a thrash of seizures at the end. Patients, terrified of the disease in the wards, walked out of the hospital, or if they couldn’t walk, their relatives

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The disease was savage, with a “rapid evolution to death after a mean of three days,” he wrote. As he studied the signs and symptoms, Dr. Ngoy Mushola came to believe that he was seeing an unknown disease—a disease that had never been described by doctors and didn’t have a name. J. J. Muyembé wasn’t so sure. In medicine,

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shocking sight. J. J. Muyembé had never seen an abandoned hospital in Equatorial Africa. African hospitals were always busy places, crowded with patients and their families and filled with activity—crying babies, people milling around, nurses discussing things, smoke drifting, food vendors walking around offering food for sale. The Yambuku hospital had been treating six thousand to twelve thousand patients a month, but now it lay deserted. So far, Muyembé and Omombo hadn’t seen any person with the disease.

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Muyembé bent over the crib and saw an infant boy writhing in agony. He couldn’t tell what was wrong with the baby. What had happened to the child’s parents? Did the baby have the disease? There didn’t seem to be anything Muyembé and Omombo could do to help the child. About five minutes after they found the baby, it stopped breathing and gave up its life.

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together in a mathematical pattern. The pattern of the interlocking proteins in a virus is far more complicated than a snowflake. The protein capsule is sometimes wrapped in an oily membrane. Inside the capsule there is a small amount of DNA or RNA, the molecules that contain the genetic code of the virus. The genetic code is the virus’s operating system, or wetware, the complete set of instructions for the virus to make copies of itself. Unlike a snowflake or any other kind of crystal, a virus is able to re-create its form. It would be as if a single snowflake started copying itself as it falls, and those copies of the snowflake copy themselves, creating ever-growing numbers of identical copies of the first snowflake, until the air is filled with falling snow,

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Many virologists feel that viruses are not truly living things. At the same time, viruses are obviously not dead. Virologists like to describe them as life forms. The term is a contradiction: How can something be a form of life that isn’t alive? Viruses carry on their existence in a misty borderland that lies between life and death, a gray zone where the things we encounter are neither provably alive nor certainly dead. One way to understand viruses is to think about them as biological machines. A virus is a wet nanomachine, a tiny, complicated, slightly fuzzy mechanism, which is rubbery, flexible, wobbly, and often a little bit imprecise in its operation—a microscopic nugget of squishy parts.

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Viruses are subtle, logical, tricky, reactive, devious, opportunistic. They are constantly evolving, their forms steadily changing as time passes. Like all kinds of life, viruses possess a relentless drive to reproduce themselves so that they can persist through time.

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When a virus starts copying itself strongly and rapidly in a host, the process is called virus amplification. As a virus amplifies itself in its host, the host, a living organism, can be destroyed. Viruses are the undead of the living world, the zombies of deep time. Nobody knows the origin of viruses—how they came into existence or when they appeared in the history of life on earth. Viruses may be examples or relics of life forms that operated at the dawn of life. Viruses may have come into existence

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Yellow fever, a severe and sometimes fatal disease caused by the yellow fever virus, has a high fatality rate. The fatal form of the disease is known as fulminating visceral yellow fever. A person dying of yellow fever has a high fever, excruciating abdominal pain, and can have black vomit. The virus, as Muyembé well knew, is transmitted from person to person through the bites of mosquitoes. The mosquito, in turn, has caught the yellow fever virus by biting a person who is infected with it. Yellow fever tends to erupt in small communities in the tropics, places like Yambuku, where the virus can amplify itself in the local population like a fire going out of control.

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He filled about twenty glass tubes with blood. Some of these people, like the pregnant nurse, were hemorrhaging from the stick of a needle, and their blood wouldn’t clot. As he drew blood and tried to stanch the

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Muyembé had never seen a rash like this. It was another anomaly. It now seemed to him that he was seeing a polymorphic disease. This is a disease that takes different forms in different people at different stages of the illness. A polymorphic disease is difficult to recognize because it is a shape shifter, a disease with many faces. To try to see the whole shape of the Yambuku disease was like looking at reflections of sunlight moving

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infectious agent was traveling on the Friendship, too. Along with the humans, it was headed ultimately for Kinshasa, a city with a population of two million, and with airline connections to cities all over the world.

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virus is a member of the filovirus family, and it is a parasite that exists, normally, in some creature that inhabits the ecosystems of Equatorial Africa. This creature is the natural host of Ebola. It may well be a type of bat, or some small animal that lives on the body of a bat—possibly a bloodsucking insect, a tick, or a mite. Occasionally a few particles of Ebola escape from Ebola’s natural host and enter the bloodstream of a person. The virus begins replicating in the person’s cells. Ebola multiplies to extreme concentrations in the bloodstream. When a person dies of Ebola, a drop of their blood the size of the “o” in this text can easily contain a hundred million particles of Ebola. Ebola can destroy a person’s immune system in seven to ten days. HIV requires years to wipe out a person’s immune system. Ebola patients typically become disoriented or deranged: The virus affects the brain in some unknown way, and it causes a change in the person’s facial expression, giving the face a masklike appearance. Ebola patients die suddenly, in a cascade of shock, and often, at the point of death, their bodies shake

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Despite its ferocity in humans, Ebola is a life form of mysterious simplicity. A particle of Ebola is made of only six structural proteins, knitted together to become an object that resembles a short strand of cooked spaghetti. An Ebola particle is only around eighty nanometers wide and a thousand nanometers long. If an Ebola particle were the size of a real piece of spaghetti, then a…

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fatal infection. Ebola is transmitted among people through direct contact with liquids that come from the body, especially blood and sweat. Once an Ebola particle enters a person’s bloodstream, it drifts until it sticks to a cell. The particle is pulled inside the cell, where it takes control of the cell’s machinery and causes the cell to start making copies of it. Most viruses use the cells of specific tissues to copy themselves. For example, many cold viruses replicate in the sinuses and the throat. Ebola replicates in all tissues of the body except for the skeleton and the large muscles of the skeleton, and it has a special…

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Each Ebola particle is studded with about three hundred soft knobs. The knobs help the particle get inside a human cell. Inside each Ebola particle is a tube made of coiled proteins, which runs the length of the particle, like an inner sleeve. Viewed with an electron microscope, the sleeve has a knurled look. Like the rest of the particle, the sleeve has been shaped by the forces of natural selection working over long stretches of time. Ebola’s family of viruses, the filoviruses, appear to have been around in some form for millions of years. Within the inner sleeve of an…

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one recent count, an Ebola particle has 18,959 letters of code in its genome. This is a small genome, by the measure of living things. The human genome, for example, has around 3.2 billion letters of DNA code, and the loblolly pine has 22 billion letters of code. Viruses such as Ebola, which use RNA for their genetic code, are…

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Yambuku, in 1976, a few particles of Ebola slipped out of an animal that lives in the central African rain forest and got into the bloodstream of one person. The first human victim of Ebola at Yambuku has never been identified. The person may have been a forty-two-year-old schoolteacher at the Yambuku mission named Antoine Lokela, who died in the mission hospital on September 8, 1976, with severe hemorrhages coming from the openings of his body. He gave the virus to his wife, Sophie Lisoke,

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died, but survived her illness. Sophie Lisoke was the first known survivor of Ebola disease.

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Nobody knew then, nor does anybody know now, where emerging viruses are going or what one of them might become. The human host has been gathering itself into gigantic supercities, teeming urban megahives packed with tens of millions of individuals jammed into a small space, who are breathing one another’s air and touching one another’s bodies. The supercities are

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growing larger all the time. Many of the world’s largest supercities are crowded with people who have little or no access to doctors and medical care. The cities are connected by airline routes, and the human host has zero immunity to any emerging virus. Ebola is roughly as contagious as seasonal

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The older children would gather around the hole at the base of the tree, holding sharpened sticks, and they’d spear the bats. They roasted the bats over the fire on their sticks as if they were marshmallows. Unlike some adults, the kids had no problem eating flying mice. They would eat the roasted bats straight off the stick, and they often shared bat-on-a-stick with one another. Émile was a toddler, too small to be able to kill or

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the little boy might have gotten a bite from a bat fly. A bat fly is a blind, wingless fly that drinks the blood of bats. It has long, jointed, hairy legs, like a spider, and it is a good crawler. Bat flies are found in bat roosts, where bats hang crowded together, and the flies crawl from bat to bat, sucking their blood. Possibly a bat fly crawled onto Émile and bit him. The fly might have had some bat blood in its mouthparts,

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On Christmas Eve, the boy came down with diarrhea. It turned into a black liquid, and he died on December 28, in his mother’s arms. A week after Émile died, his four-year-old sister, Philomène, also got black diarrhea and died. In villages in Africa where houses don’t have running water, women often use their bare hands and saliva to clean children who throw up or soil themselves. After Philomène’s death, the children’s mother came down with a fever. She died on January 11, 2014. She was twenty-five at the time of her death. Her family buried her next to her house, as is the tradition in West Africa. Shortly afterward, her mother, Philomène’s and

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The village midwife had nursed the children’s mother and grandmother while they were sick. Not long afterward, the midwife broke with a fever. By this time the village was starting to get really frightened by the chain of deaths. The midwife’s relatives got very worried about her and took her to a hospital in a small city called Guéckédou. The city, with a population of 200,000, is in Guinea.

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is seven miles from Meliandou. The midwife died in the Guéckédou hospital. Then a medical worker at the hospital, who’d taken care of the midwife as she died, came down with the sickness. This medical worker decided to seek care at a hospital in a town called Macenta, which is forty miles from Guéckédou. The medical

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The child had been killed, and he had started a chain of infections in a few more people. The virus started amplifying itself in two places in Guinea, and then it jumped to more places, and soon a viral fire was smouldering in the Makona Triangle.

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The villagers helped Leendertz’s team trap bats and rodents so they could see if the virus had come from any of these animals. The villagers also shared a great deal of information about the way they hunted wild animals, about who had died in the village and when, and about their funeral practices.

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learned that nobody in the village had gotten sick from direct exposure to or eating the bats. This would suggest that the virus didn’t come from the bats. Or it would suggest that only a few of the bats carried the virus, while most of the bats did not. That is, the virus could be a rare disease of the bats, a disease that most of the bats never catch. Bats have their own rare diseases, of course, just as humans do. In any event, none of the rodents or other kinds of bats that the team members and villagers collected was carrying a deadly virus.

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The man realized he was dying, and he asked his family to carry him into a patch of sacred forest. They placed him on the ground under the trees, where he died surrounded by his loved ones. Afterward, following local tradition, the man’s friends and family members took turns lying next to his body in the forest. They embraced the body, wept over it, and ate meals next to it during which they served foods that the man had liked. This was a way of remembering the man and cherishing their love for him. The disease attacked some of the mourners afterward.

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On the other side, in a bustling town in Guinea, she either hired a ride-share taxi or got on a jitney bus, which in that area is called a buda-buda. During the ride, she sat next to a passenger who was sick. Back in Kpondu village, after visiting her son in Guinea, Ms. Koniono came down with diarrhea and vomiting.

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We wouldn’t know about the existence of Menindor or any details about her if not for remarkable epidemiology and investigative reporting done by Dr. Sheri Fink and colleagues of hers at The New York Times, who traced the early spread of the virus in Sierra Leone. Menindor was a beloved figure in the villages along the Makona River. Many of her patients were women and young girls, and they came from villages far away to be healed by Menindor. The local people believed that Menindor kept a powerful snake in a chest in her house. This was no ordinary snake, but a supernatural being.

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Five of Ms. Koniono’s sisters washed her body. Following the usual practice, they gave the body a kind of enema, which purged the contents of the bowels and cleansed the body internally. This is something important to do in a tropical climate, or the body deteriorates rapidly. Then they poured clean water over the body. Ms. Koniono’s body was brought back to Kpondu village. A day later, her relatives took her body to a spot a few miles away, and gave her a burial. In the following weeks, in Guinea, all five of Ms. Koniono’s sisters reportedly died. In Kpondu, Sierra Leone, Menindor was seeing more patients with the illness, and many of them were women and girls. She tried all her medical arts, all her secret weapons, but nothing seemed to work.

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He was a virologist who specialized in Lassa hemorrhagic fever, which is a devastating and frequently fatal disease caused by Lassa virus, a Biosafety Level 4 virus that invades the brain and causes hemorrhagic bleeding. BSL-4 viruses, or Level 4 viruses, are sometimes referred to as hot agents. They are lethal, highly infective viruses for which, in almost all cases, there is no vaccine, no cure, and no effective treatment. If you catch a Level 4 virus, there is very little any doctor can do for you other than keep you hydrated and prevent you from having any contact with anyone else. In many countries, including in the United States, regulations require researchers who are handling Level 4 viruses to wear a whole-body pressurized biohazard space suit

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independent, filtered air supply. In addition, the space-suit research must be conducted inside a Biosafety Level 4 laboratory. A Level 4 lab is sometimes called a hot lab, a hot suite, or a hot zone. It is a group of rooms that are sealed off from the outside world and are only accessible through an airlock that is equipped with steel doors and a chemical shower. The shower is used for decontaminating the space suits of researchers when they make an exit from the hot zone.

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The Lassa research program at Kenema Government Hospital is dedicated to giving care to Lassa patients, to tracing and stopping outbreaks of Lassa fever in the countryside, and to pursuing research on the virus in the hope of someday eliminating the disease.

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The French investigators had learned that some of the patients had had hiccups. This detail really caught their attention. Hiccups are a classic sign of Ebola virus disease.

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James had hemophilia, an inherited disease that causes the blood to fail to clot normally. A hemophiliac can bleed endlessly from a small cut, and can have dangerous internal bleeding after getting a blow to the head or body. James’s hemophilia was mild and easily treatable, but when he had been a baby Hensley had decided to carry him up and down stairs to prevent him from taking a fall on the stairs, especially when he was learning to walk. Now, at age nine, he was an active, healthy, athletic boy. He went up and down the stairs all the time, except that she still carried him downstairs in the morning and upstairs to bed at night. It had become sort of a tradition, and they both liked it.

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National Interagency Biodefense Campus. The campus consists of a group of

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they died like flies, as if they were in a fourteenth-century plague house. About the best doctors could do for Ebola patients was to give them water and hope for the best.

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The most recent evidence suggests that the most common type of HIV made a cross-species jump out of one chimpanzee into one person around 1910 in southeastern Cameroon, along a tributary of the Congo River. From that first human host, HIV began spreading from person to person, amplifying itself in the human species until it reached every community

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taking off a pressurized biohazard space suit, passing through airlocks, and using a decon shower to sterilize the outside of the suit. Situational awareness—knowing exactly where your hands are at every moment. Handling needles and sharp instruments with extreme care. Hensley loved working in Level 4. Doing research in hot labs became almost an addiction for her, and she became fascinated with Ebola virus. It was really something to hold a flask containing a liquid suspension of ten billion particles of Ebola in her gloved hands inches from her space suit’s clear faceplate visor. You always had to wonder what this virus could do to the human species if it got a big chance to amplify itself in human bodies.

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Zaire Ebola. Zaire was the first Ebola to be discovered, when it broke out in 1976 at Yambuku Catholic Mission in Yambuku, Zaire.

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At this writing there are six known species of Ebola. The six Ebola sisters. In order of discovery, the six Ebolas are named Zaire Ebola, Sudan Ebola, Reston Ebola, Taï Forest Ebola, Bundibugyo Ebola, and Bombali Ebola. Each species of Ebola has its own identifiable genetic code and is somewhat different from the others. Zaire is the most lethal of the six Ebolas; it is the homicidal elder sister. In the 1976 outbreak, Zaire Ebola killed 88 percent of its victims, though in subsequent outbreaks it killed roughly 60 to 70 percent. Zaire Ebola is not only the most deadly of the five Ebolas, it is also the most deadly of all the known filoviruses, the family of viruses that includes the Ebolas. Zaire Ebola is the lord of the strains.

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been found exactly nowhere except in the blood of the Danish boy—he is the only individual who is known to have been infected with Ravn. Still, Ravn could break into the human species again from its hidden reservoir in nature. Hensley also did research on a Level 4 emerging virus called Nipah. Nipah is a bat virus that causes personality changes and liquefaction of the brain. Nipah is only moderately infectious, but it gets into the lungs, and there is a certain alarm among experts that the code of the virus could change and turn the virus into a sort of brain-destructive neurological cough that travels in the air. There is no vaccine or treatment for Nipah disease.

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Hensley would get a panicky call from his school saying he’d cut himself and needed to be picked up. She’d take him home and watch his cut, and sometimes it would heal and sometimes it wouldn’t. If it was still oozing, she would drive him to Johns Hopkins Hospital in Baltimore, where his doctors would give him clotting factor, and he’d heal immediately. The trips to Johns Hopkins were infrequent but unpredictable. As his mother, she felt she should be there for him. On the other hand, people were dying, and she was one of the few people in the world who knew much about filoviruses like Ebola.

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zone. The red zone is surrounded by a maze of plastic fences, to separate infected people from everybody else. As long as a patient’s blood tests are positive for Ebola, the patient isn’t allowed to leave the red zone. Patients die in the red zone; they are not permitted to die anywhere else. When staffers exit the red zone, workers spray them with bleach before they take off their equipment, to sterilize it and kill any Ebola particles that are clinging to the gear. An Ebola patient who recovers is discharged from the red zone and allowed to go home. The bodies of patients who die in the red zone are placed inside double body bags, and are buried close to the camp. The red zone has pit toilets that are inside plastic sheds.

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The red zones of Doctors Without Border were, in effect, giant plastic bags in which people infected with emergent Ebola were kept. This technique trapped the virus inside the plastic bag, where it would work its way through the human bodies in the bag, killing many of them—but the virus couldn’t escape from the bag. The red zones were artificial walls placed around hot spots of Ebola in order to break the growing chains of infection in the human species.

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first appearance, in 1976, there had been nineteen outbreaks of Ebola, and very few people had caught the virus. Never more than 280 people had died in any Ebola outbreak. In thirty-seven years of outbreaks, the six different Ebolas had killed, in all, only 1,539 people, according to reported deaths. The death toll from Ebola was virtually nothing in the annals of infectious disease: Each year, tuberculosis kills around 1.3 million people. Over the years, as Doctors Without Borders slammed down Ebola successfully, a widespread view developed among public health experts that Ebola wasn’t much of a problem for the human population of the world and

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never would be. It is fair to say, however, that nature often does whatever is necessary in order to make the most number of experts wrong.

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heart failure, HIV, AIDS, and cancer. Patients with serious conditions often went to herbalists and faith healers first, and by the time they got to Khan’s office it could be too late. He saw women with breast cancer whose tumors had broken through the skin, and he saw men with prostate cancer that had spread into their spines, leaving them paralyzed. He did what he could. For advanced cancer patients he prescribed palliative care. If a cancer patient could afford the cost, he’d send the person to Freetown, the capital of Sierra Leone, for

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holds in God,” which was one of her favorite expressions. It means that God holds all the power and keeps his plans hidden until events come to pass.

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surveillance team visited villages along the Makona River, asking questions, describing the symptoms of Ebola, and looking for anybody who might have it. They came up empty-handed. The villagers said they hadn’t seen this disease.

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expert in infectious disease ecology, which is the study of the way ecosystems, viruses, and people interact. Each year, Moses lived in Kenema for several months, doing research. She spoke Krio, one of the two national languages of Sierra Leone (the other one is English). She also spoke some Mende, an ethnic language. When Moses was stationed in Kenema, she spent time in the countryside, trapping rats and testing their blood for Lassa virus, watching the virus’s hidden movements in the ecosystem and through people.

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But her knowledge of the countryside was partly in her head. The maps of the Makona Triangle aren’t reliable. The landscape is dotted with tiny villages, typically spaced a few hundred yards apart. Different villages often have similar or identical names. In Krio the same word can often be spelled several different ways. Therefore the name of a village could appear under several different spellings on different maps. Furthermore, many villages were just a dot on the map—no name at all. And there were uncharted villages, small communities that didn’t appear on any map. Some of them were reachable only on footpaths.

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given care according to the rules of Doctors Without Borders. Those who died in the red zone were buried near the camp. As the virus continued to spread, local people got increasingly fearful of the Doctors’ treatment units. The camps, with their white tents, had a sinister look, and they were being run by white foreigners. The foreigners were telling people that they were infected with a virus and must go into the camp, and those people were vanishing in the camps, never to be seen again. Foreigners dressed in moon suits were carrying white bags with dead bodies inside them out of the camps and burying them next to the camp. Nobody was allowed to open the bag and look inside at the loved one, because the foreigners said the corpse

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People in the Makona Triangle had never heard of Ebola. Many people didn’t believe in the infectious theory of disease—the idea that diseases are caused by invisible microbes. Plenty of people in Kissi country had mobile phones, and they used social media to discuss the situation. Text messages started flying around the Makona Triangle, rumors about the camps. The white foreigners, went the rumors, were injecting chlorine into people and

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a group of powerful foreigners who spoke no English, or spoke it badly with a heavy accent, were to set up a camp of tents in suburban Wellesley, Massachusetts, and they were wearing biohazard moon suits and were telling townspeople that an extreme virus had gotten loose in Wellesley and that anybody who had symptoms must go into the camp and stay there until they died, there might be some opposition from the Wellesleyites. And if most people who went into the camp were never seen again, dead or alive, and if the foreigners were burying white body bags next to the camp, and

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few of the bags obviously held dead children, and if social media lit up with rumors of hideous experiments, it’s a pretty sure bet that the Wellesleyites would be reaching for their guns and doing anything they could to get the hell out of Wellesley. “It’s your darkest nightmare,” Armand Sprecher explained.

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“relatively small still” and there was “no need to overblow something which is already bad enough,” and “there has never been an Ebola outbreak larger than a couple of hundred cases.” And this new outbreak was no bigger than any of the others—it was just a typical Ebola outbreak.

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Leone, if it hadn’t done so already. It was just common sense to think that the virus would cross the river. At the same time, Moses and Khan felt that there wouldn’t be more than a few dozen Ebola cases in

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There was no reason to suppose that Ebola would go far in Sierra Leone; the consensus view among public health experts was that Ebola was not a serious threat to the human population of the earth, and that the virus could be controlled fairly easily. KPONDU VILLAGE, SIERRA LEONE April 1–8 Menindor the healer was now very sick, lying in bed in her house. It was a small house made of mud bricks. Menindor’s mother, who lived in a nearby village called Sokoma, moved into Menindor’s house and took care of her, but there was nothing she could do to help her daughter. Menindor’s sister also cared for her. On April 1, while Menindor lay dying in Kpondu, a doctor in Freetown named Jacob Maikere, who was working for Doctors Without Borders, circulated by email an English translation of a report from Guinea’s Ministry of Health. Maikere sent

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Lina Moses was having trouble getting her email. The Internet connection in Kenema was bad, and so she didn’t see the email in question. The report seemed to say that a woman got Ebola in Guinea, died in Guinea, and was buried in Guinea. It stated that the woman’s dead body was taken to “Gbandu,” but the report did not say that Gbandu is in Sierra Leone. In fact, there is a village in Guinea called Gbandou. Gbandou, Guinea, is three and a half miles from Kpondu, Sierra Leone. And the name of Menindor’s village in Sierra Leone has four different spellings, Kpondu, Gbandu, Koipondu, and Koipind. How could anybody guess that Gbandu and Koipind are the same village, and are in Sierra Leone? This illustrates the nightmare of identifying villages in the Makona Triangle.

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Menindor died in her house in Kpondu on April 8. Her death rocked the villages along the Makona River. As the news spread that Menindor was gone, there was an outpouring of grief, especially among women. Menindor’s family began planning a large funeral, and hundreds of people from villages on both sides of the river made plans to attend. Outside the villages, Menindor’s death went completely unnoticed.

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others. “The whole secret of the transmission of Ebola,” Kallon said, “is that you wash the body with water, and then the water is collected and used again.” The wash water from the corpse was carefully stored in a container. Then family members would use the water in a ceremony of grief and remembrance. “If you are the son of the dead person, you wash yourself with this same water, the water that washed the body,” Kallon explained. “After that, the daughter washes herself with the same water that the son used.” The washing ceremony was sometimes done in a grove of sacred trees, a patch of old forest. It was a type of ceremony similar to the one in which mourners ate a meal of the deceased person’s favorite foods while sitting next to the body of the deceased person in a forest. During the water ceremony, family members sometimes drank the wash water, Kallon said. It was a way of bringing

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themselves. Ebola victims sweat profusely. The sweat glands pour out vast numbers of Ebola particles mixed with perspiration. The sweat clings to the skin and evaporates, leaving a film of Ebola particles behind. More sweat comes out, and more particles build up on the skin. By the time a person dies of Ebola disease, the corpse is painted with Ebola particles. There can easily be ten million Ebola particles sitting on a square inch of the corpse’s skin. Only one particle can cause an infection in another person. Ebola particles are quite tough as long as they are kept moist. Experiments have revealed that Ebola particles can stay potent for up to seven days while they’re sitting on the skin of a decaying corpse.

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remember when my father died. I was with him at the time. My mother was there, too. As his breathing settled down, my mother held him close, and I put my arms around my mother. Then, after a few moments, I reached out and placed my hand on my father’s face, feeling his skin, still warm to the touch, my father, as the life went out of him. I couldn’t help but touch him as he went away. At the funeral of Menindor, as people expressed their grief and touched Menindor and touched one another, some of the particles that had once coated her bare skin were transferred from person to person until the crowd got smeared with Ebola. People got particles on their fingers and hands, on their faces, in their hair and clothing, and in their eyes. Ebola virus moves from one

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Eventually, somewhere in the person’s body, the particle sticks to a cell. The core of the particle gets pulled inside the cell. Now one Ebola particle is sitting inside one cell in the person’s body. At this point, the person may be doomed.

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particle’s broken core, like thread whirling loose off a spindle. Next, the code takes command of the cell’s machinery and forces the cell to start making copies of the Ebola particle. Eighteen hours later, the cell is oozing newborn threads of Ebola, which grow out of the cell like hair, break off, and are carried away in the bloodstream. Each infected cell spits out up to ten thousand new Ebola particles. The particles end up everywhere in the body, infecting more cells, and each cell spits out thousands more Ebolas. This is known as extreme amplification of a virus. Soon the body is flooded with particles, and the person’s immune system collapses. At the time of death, vast numbers of cells all through the person’s body are converting themselves into Ebola particles. Ebola particles are made entirely out of human material: Ebola is an anti-human metamorphosis of the human form. The amplification of Ebola virus in the human body is one of the dark wonders of nature.

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Some of the infected individuals sought help elsewhere, help from doctors and hospitals, from family members, from healers, and in different nations within the Makona Triangle or outside the Triangle. The network of human connection, going hot with a virus, extended into the cities of West Africa. The funeral of Menindor appears to have been a central, germinal event in what would become a full-scale epidemic of Ebola in the human species, the most destructive, fast-moving expansion of any lethal infectious agent during the past hundred years.

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death and burial went unnoticed by Humarr Khan and his team. If Khan’s team had seen the report and had realized its significance—that Ebola was already in Sierra Leone, and was active in Kpondu, then it seems certain that they would have sent a surveillance team to Kpondu village to find

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Maybe or maybe not. We will never know, because this is not the way reality played out. And this is not to say that Humarr Khan and his team are at fault for anything. They are not at fault. It is to say that history turns on unnoticed things. Small, hidden events can have ripple effects, and the ripples can grow. A child touches a bat…a woman riding on a bus bumps against

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Ebola is not a thing but a swarm. Ever since a few particles of Ebola had slipped into the boy, the virus had been copying itself in ever larger numbers of people. It was a vast population of particles, different from one another, each particle competing with the others for a chance to get inside a cell and copy itself. As the particles copied themselves, there were errors in copying, and slightly different kinds of Ebola emerged in the swarm. You could imagine the virus as a school of fish, with each particle of Ebola a fish. The fish were swimming, and as they swam and multiplied they changed, until the school had many kinds of fish in it and was growing rapidly in size, with some kinds of fish better at swimming than others and with sharper teeth.

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Ebola arose in the Makona Triangle. This mutant Zaire Ebola was four times better at infecting human cells. The mutant had a special affinity for human cells. It was a fish…

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change in Zaire Ebola happened in just one letter of its genetic code. The virus that was spread at Menindor’s funeral, the mutant, the changed Ebola, is officially named the A82V Makona Variant of Zaire Ebola. In this book it will be referred to simply as the Makona strain or the hot Makona. Scientists think it first arose as a single mutant particle of Ebola in the body of some unidentified person who lived near or in the city of Guéckédou, Guinea. That one mutant particle of hot Makona, that one fish with sharper…

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The Makona strain really gets into human cells easily. The strain may be able to spread through a person’s body faster and more powerfully than any other kind of Ebola—but this has not been proven. The Makona may be more contagious than any other Ebola, easier to catch. It could be hotter—more lethal—than any other filovirus, even hotter than Zaire Ebola. We really don’t understand the exact characteristics of the Makona strain. But by now there is…

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funeral of Menindor we are seeing something that resembles a high-speed movie displaying the first instants of a nuclear explosion. We are looking into the core of the expanding fireball right at the start of detonation. The funeral produced an unseen biological flash of a new virus, and the virus began explosive amplification in the human species. Ninety miles away, at the Kenema hospital, nobody saw the flash, nobody was aware of it. The staff of the Kenema hospital didn’t know that something had happened that would lead to the deaths of many of them. Nobody anywhere noticed the movement of the mutant virus as the Makona strain began to…

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“It’s a PAPR,” she said. “That means positive air pressure respirator. It runs from a battery, and I attach it to my suit. It filters the air I’m breathing inside the suit. And it keeps my suit pressurized.”

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As for James’s question, she had no idea what Ebola would do to him. Ebola had never been observed in a person with hemophilia. Ebola makes people bleed, and their blood won’t form clots. The same thing happens with hemophilia.

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a rapid-deployment Biosafety Level 4 field lab for testing blood.

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Liberia at that time was genetically close to the Zaire Ebola that jumped into the little boy in Meliandou. In other words, the first kind of Ebola to enter Liberia was wild Ebola, fresh from the ecosystem. The A82V Makona Variant, the Makona strain, the mutant, which had first appeared in Guinea just a few weeks earlier, was still jumping around the Triangle, and hadn’t made a breakout for the cities. And nobody knew the Makona strain existed.

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The death of Menindor’s husband impressed people and frightened them. Many people in the area believed that diseases were caused by malignant forces. They were aware of the story that Menindor had been keeping a supernatural snake inside a chest in her house. After she died, a story went around that Menindor’s husband had very foolishly opened the chest. The reptile had escaped and killed him, and now the snake of Menindor was going around

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The residents said that a famous healer, a woman, had died in the village. She had been a leader of women. Her name was Menindor. She had become sick and died.

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No, she had failed with the law of the smoke, the villagers said. Michael had no idea what that was. He wasn’t going to argue with the villagers about their explanations for diseases. He just wanted to know if the healer’s disease had seemed like Ebola.

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No, it wasn’t Ebola, the villagers said. In addition to failing the law of the smoke, the healer had failed her responsibility with the snake, and this was the cause of her death.

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then a little boy had died. The reason for the boy’s death was that Menindor had prepared a magic flagstone and placed it in the lintel of the door to her house. Menindor’s magic stone had been removed from the doorway and this had caused the boy to die, they said.

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Gbakie and his partner were using a translator who was helping them with the Kissi language. Using the translator, they said, “But we want to tell you that Ebola is close to you,” they said. “You have to be very watchful for Ebola.” If anybody had symptoms of this disease, they should go to the community health clinic in a town called Koindu. The head of the Koindu clinic was in contact with Humarr Khan, and would

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Michael Gbakie and his team returned to Kenema on May 8, thinking that the death of the healer Menindor had occurred a short time before then. In fact, her death had occurred exactly a month earlier, on April 8. The Makona strain had been moving out of her funeral for a month, and had not yet been noticed. It seems that the villagers were aware of Ebola, but possibly they didn’t want to disclose all they knew out of fear they would end up in a camp. And so Michael Gbakie and his team had come close to the Makona strain, but it had slipped past them.

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local legend said that the egrets were watchers who looked down on the world and protected all the other animals on the earth: cattle, goats, crocodiles, lizards, even snakes. The protection of the egrets did not extend to the flies, however. The flies were too small and too numerous for the egrets to

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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?”

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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.

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am crying,” she said to the room, “because I myself have gone through the arms of Lassa fever, and I know that Ebola is worse.” Like the other nurses in the Lassa ward, she was a survivor of Lassa hemorrhagic fever. Her illness had been dreadful, and she had fallen into a coma and nearly died. As she had started to recover, she had gone bald. Lassa virus had killed the roots of her hair. She also fell into a serious depression. Years later, her depression had lifted and much of her hair had grown back, but she wore a wig to cover up the damage. “Ebola is more virulent,” she said to her colleagues.

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After the meeting, Veronica Koroma walked up the hill to the Lassa ward to start the day’s work. In a few minutes, she would be coming face-to-face with Ebola patients for the first time in her life. She had never seen the disease, and she was very afraid. At the entrance to the ward she met her boss, Mbalu Fonnie. “Oh Auntie, I’m so afraid and so scared,” she said, and started crying again.

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“Oh, shit!” “What?” she asked “Shit! The stool cups!” The motorbike courier, after dropping off the tube of blood from the clinic, had delivered several cups of feces to a government lab in Freetown, to be tested for cholera. But the patient had Ebola. “Those cups are hot!” Khan exclaimed. It was the world’s hottest shit. They burst into morbid laughter, they couldn’t help themselves, but it was a dangerous situation. Khan would have to call the Freetown lab and warn the workers not to open those cups, and to sterilize them.

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They refused to accept the idea that Ebola was real or that their mother had the disease. Khan couldn’t change their minds about this, and eventually he brought Satta’s children to Nadia Wauquier’s cargo-container lab to show them how the blood test worked. Nadia displayed their mother’s results on a computer screen and explained how the test was done.

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Satta’s children listened attentively. They were bright kids. They told Khan that they wanted their mother’s blood sent to a second laboratory in order to cross-check the results. Nadia later wrote in her journal:

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seemed to be quite educated. I told them that…the only option would be to send it [their mother’s blood sample] abroad, whether Europe or the US. I assured them they would get the same result. Then they started asking more moving questions such as “what are the chances of survival?” “is there a cure or a vaccine?” I looked at Khan to see if he would help me but he shook his head and told me to go on and answer. Telling children that their mother has an 80% risk of dying is not an easy thing. They took it fairly well….They thanked me sincerely for talking with them and moved out under the rain. I saw them again a few minutes later, outside. The young girl was crying.

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was Michael Gbakie’s job to get the team dressed properly and to make sure they made no mistakes when they were inside the clinic and exposed to an Ebola patient.

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is normal in African medical care units, there would be family members in the building taking care of loved ones. The family members might be very protective of the patients. Any of the family members could have Ebola,

Sometime your entire way of life stands in opposition to something but you never know till that thing emerges

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The drivers included the Kissi man, Sahr Nyokor. Then Michael and the others entered the building, which was now, they knew, a nest of Zaire Ebola, the red queen of the filoviruses.

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The team asked the family to stop giving her care and not to touch her. They began exploring the clinic more carefully, examining patients, and to their surprise they discovered eight more patients who were showing symptoms of Ebola disease. Strangely, all of the suspected Ebola patients were women.

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could be isolated so she wouldn’t spread the disease to other people. He had no legal power to force her to get into the ambulance. As a patient she had freedom of choice.

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“The relatives raised their eyebrows at that idea,” Michael recalled later. “They made references to the MSF [Médecins Sans Frontières/Doctors Without Borders] treatment center in Guinea. They said in Guinea people had been taken to the treatment center and it was the end for them.”

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almost four hours, discussing the matter with Ms. Lebbie’s relatives, but the relatives remained firm: She was to stay in the clinic.

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The youths, Nyokor told him, were planning to attack the team. They were going to burn the vehicles, so the team couldn’t escape, and then they were going to move in on

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Still wearing their moon suits, they ran out the front door and found themselves facing a group of hostile young men holding rocks in their hands. They were close to the vehicles, and had cut off the team’s means of escape.

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Gbakie and his co-leader, an epidemiologist named Lansana Kanneh, exchanged quick words. They decided that their best chance was to try to reach the town’s police station. It was four hundred yards away.

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As the young men closed in, the team broke out. They sprinted toward the police station, keeping together, and it turned into a desperate, four-hundred-yard dash. The young men went after them, hurling rocks. The rocks were the size of apples and came in on skull-fracturing trajectories. The team members, looking over their shoulders and dodging the rocks, made it to the police station and flew in through the door, gasping, while the crowd pulled up just outside. None of the team members had been hit.

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symptoms had disappeared from the clinic, including Mamie Lebbie. Their beds were now empty.

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What had happened was this: People had phones, people had motorbikes, and news had spread fast. The families of the sick women had organized a rescue. It takes about twenty minutes to drive by motorbike from villages near the Makona River to Koindu. Under cover of darkness, people riding motorbikes had come out of the villages and converged on the clinic, and had gotten their loved ones out. They put the nine Ebola-infected women on the backs of the motorbikes and carried them to safety, to be hidden in the villages or taken across the river to Guinea. Mamie Lebbie—it was later learned—was carried on the back of a motorbike to a river crossing,

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was taken into Guinea. (Weeks later, she surfaced alive, and eventually gave some interviews to local news media—she was an Ebola survivor.)

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next day they returned to the area around Koindu and began driving through the nearby villages, asking questions, looking for the nine women who’d been spirited out of the clinic. They were also looking for more people with signs of Ebola. Local people were reluctant to talk with them. And the villagers were clearly hiding the suspected Ebola patients.

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“How de patrol? How de patrol?” the kids asked. “I tell God thanks it was not so bad,” he said. “No’r touch me”—don’t touch me—he said firmly to the children.

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into the tub of bleach solution. He scrubbed his clothing with the brush, churning the clothes thoroughly. He would let them soak in the bleach water for thirty minutes. This was a validated kill time for Ebola particles. Next he slowly poured the bucket of water over himself, soaping his entire body carefully, rinsing himself, and he dried himself with a clean towel. He wiped his wristwatch with an alcohol swab to sterilize it, and put it on his wrist.

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Naked except for his wristwatch, and now presumably free of Ebola particles, Michael Gbakie wrapped a towel around himself, got his feet into the plastic sandals, and walked across the yard and went inside the house. In the bedroom, he put on clean clothes. Then he went into the parlor, and at last embraced his wife and the children.

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told them how the villagers had attacked the team and chased them, and how their vehicles had almost gotten torched, and how they’d discovered and lost nine Ebola patients, and how people didn’t believe that Ebola was real. The children were spellbound. Zaiinab got really frightened, especially when he told her that he and the team would be returning to the Ebola area tomorrow, to search for more Ebola cases. As he went to bed, Michael had a strong feeling that the situation had already gone beyond anybody’s control.

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nonpressurized whole-body hazmat suits. HEPA breathing masks. Goggles. Tall rubber boots. Nitrile surgical gloves, the kind that are resistant to tearing. Rolls and rolls of tape. You need lots of tape for biohazard work, to seal cracks and to keep a hazmat suit tight. Many, many blood draw kits, for drawing blood from patients, blood to be tested in the Hot Lab for Ebola. Infusion lines, infusion needles, and infusion bags, for administering saline solution to Ebola patients, to help keep them from getting dehydrated. Pump sprayers, for spraying bleach disinfectant. Biohazard body bags, made of white Tyvek—there were going

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This had been her dream for years. Now it was really going to happen. It was a battle of a kind, a public health battle, and the aim was to save lives. This was Zaire Ebola, and nobody who went near it could consider themselves safe. Of course she could catch it, anybody could catch it, but Moses felt a sense of confidence in her training and experience. She was a seasoned epidemiologist, she had worked with Lassa virus for years, and Lassa was a Level 4 pathogen like Ebola. She spent the afternoon pulling things out of boxes and repacking the stuff tightly into twenty-seven plastic footlockers she’d bought at Walmart.

#preparedness

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clinic and had been spirited away on motorbikes while the team was taking shelter in the police station. All of the women had been at Menindor’s funeral. The team transported all twelve women back to the Kenema hospital. Their blood was tested in the Hot Lab and came up positive for Ebola, and they were placed in beds in the ward, and were tended by Auntie and her team.

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They were supposed to remain inside the ambulance. The Ebola patient would be handled by team members who were suited up in full PPE. During the Daru pickup, however, Sahr Nyokor got out of his ambulance and went inside somebody’s house for a visit with friends or relatives. He evidently didn’t want to frighten his friends, so he didn’t wear PPE. Later it came out that

#african style

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watching. She threw a piece of rope around a trunk and cinched down the lashing. “Now look at that woman’s arms and shoulders,” one of the men remarked in Krio.

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“Oh, now look how strong she is!” another man exclaimed. They didn’t realize she knew Krio. “Her husband is a lucky man,” another man said. “He has such a strong, hard-working wife.” Moses smiled at them. She felt buoyant. A few hours later, Moses was in the Library of the Lassa Laboratory, meeting with Robert Garry, the Tulane microbiologist who was the principal American advisor to the Lassa program. Garry had flown in from New Orleans a few days earlier, bringing with him a large amount of biosafety gear. They planned strategy. Moses would immediately set up a crisis operations center in the Library. She would serve as the nexus of epidemiology and operational support for Auntie in the Lassa ward, for

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Khan, and for the surveillance team. She would keep the Lassa ward supplied with biohazard suits and medical supplies, and she would coordinate communication and operations among the disparate parts of the Lassa program. The Lassa program was the main line of defense for Sierra Leone.

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The villagers were hostile to this idea. “They were in serious, serious denial. We talked to them at length, and there were a lot of confrontations as it went on,” Gbakie later said. “They

#africanstyle

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didn’t believe at all in Ebola. It was not an easy conversation.”

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Finally two teenage boys stepped forward and said they’d do the burial. Worried about the boys’ safety, Michael and his partner got them dressed in moon suits, and they dressed themselves as well. Then they sprayed the body with bleach and got it inside a biohazard bag. They placed the bagged corpse on top of an old wooden door and carried the door with the bagged body on it to a place in the ring forest where the villagers buried their dead, and they dug a grave, sweating in

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doing. Just as they were getting ready to lower the body into the hole, all hell broke loose.

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At a signal, they began hurling rocks at the epidemiologists. Rocks the size of baseballs whipped past Gbakie and Kanneh. The two men ducked and yelled, and ran blindly into the forest and up the steep hillside, trying to find their vehicles, while the young men chased them, throwing rocks. The attackers knew the forest perfectly, and the

#african style

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Nyokor gunned the engine, and the ambulance lurched forward as a rock punched a hole in the windshield, and more rocks smashed the side mirrors. Moments later they were out of the ring forest and moving fast.

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He could now see the problem only too clearly: The local people didn’t believe that Ebola was real. The virus was out there, it was spreading, and the local people would become violent if the team tried to find it. It was very clear to him—after nearly being killed in a village—that his nation was heading for a disaster. All he could do, personally, was just keep working and try to keep his family safe.

#africanstyle

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This was to ensure that each patient got two tests for Ebola. This practice would cut down on false results, which could be fatal for a patient. If somebody tested positive but actually didn’t have Ebola, the person would be placed in the Ebola ward, where they would certainly catch Ebola. And if somebody tested negative but they actually had Ebola, the person would be sent home or placed in the general wards, where the person would spread the virus. Thus every blood test done

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Augustine Goba and Nadia Wauquier was a matter of life or death. Both Goba and Wauquier, and their technicians, were under intense emotional strain, and they were handling raw infected blood. The slightest mistake with the blood and their lives could be over. Nobody working in the Hot Lab was sleeping much.

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Tyvek material of the suit didn’t breathe. The nurses got boiling hot and soaked with sweat inside their suits. In the tropical climate, you couldn’t wear a whole-body PPE suit for more than about an hour before you were in danger of having heatstroke, which could be fatal. Auntie sent her nurses into the red zone in pairs, using a buddy system. A pair of nurses was a “hot team.” While the hot team worked inside the ward, a nurse sat outside the red zone and watched

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The patients did not seem to be hemorrhaging much, but they were having explosive diarrhea and projectile vomiting. The ward was a mess. The suffering of the patients, and the way patients who seemed stable would suddenly crash and die in minutes, filled the nurses with horror and fear. Meanwhile the nurses’ families were getting scared. The nurses were going home after working inside the Ebola ward, coming into contact with their children,

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Many family members urged the Ebola nurses to stop working, and some of the nurses began skipping work, not showing up for their shifts. This tormented Auntie. Downhill about fifty yards from

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Auntie. Lina was always running to the Ebola ward, and her flip-flops really made Nadia nervous. She thought that if Lina got a small cut in the skin of her foot, or got a little bit of blood or vomit on her foot, she could end up getting infected. She decided not to say anything to Lina about her flip-flops, though. She had to trust that Lina wouldn’t do anything stupid. Humarr Khan

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It turned out that there are very few doctors in the world who know anything about how to treat biohazardous patients who are hemorrhaging and rocket vomiting with a Level 4 virus. Khan got in touch with his friend Dan Bausch (who had talked him into taking the directorship of the Lassa program). Bausch was then working with the World Health Organization at a hospital in Conakry, Guinea, helping set up Ebola wards and bringing volunteer doctors into the fight as quickly as possible.

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England. Fletcher, an expert in delivering clinical care in Ebola outbreaks, was volunteering for the WHO as a kind of advance special operative. He went into chaotic, Ebola-ridden hospitals ahead of the Ebola doctors, where his mission was to stabilize the hospital and make it safe for the Ebola doctors who would follow him. Fletcher was carrying a single box of medical supplies. “I was worried about Khan. I knew he was getting tired,” Fletcher later said.

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that the nurses were under pressure. “They were a pretty frightened, tired group,” he recalled later. Khan told Fletcher that some of the Ebola nurses had been skipping work. They were afraid of catching the virus, and their family members had been pressuring them to stay home so they wouldn’t infect their families. Patients were prostrate, and they were vomiting and having diarrhea. The nurses were giving them fluids to drink, but the patients vomited them up, which caused the patients to become severely dehydrated.

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happens, the level of potassium in the bloodstream decreases drastically. An imbalance of potassium in the blood can trigger a heart attack. Khan was very concerned about keeping the Ebola patients hydrated. For years in his own practice he had prescribed coconut water to his patients. Coconut water was cheap, poor people could afford it, and it was rich with salts and minerals. But the patients were having trouble keeping liquids down,

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an intravenous infusion of saline solution, which could quickly bring the patient’s fluid and potassium levels back to normal. There was plenty of saline on hand at the Ebola ward, with plenty of infusion kits. But to put a needle

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an Ebola patient’s arm seemed extremely dangerous—the worker could get pricked. The Ebola teams from the International Red Cross and Doctors Without Borders didn’t ordinarily give IV saline infusions to Ebola patients—the procedure was thought to be risky, because a medical worker could get stabbed with a bloody needle. Khan and the nurses were following a standard international policy

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Patients were dying in the beds and in the cots, and the nurses were putting the bodies into biohazard body bags and removing them. Then there was the problem of food. The patients, especially children, needed to eat, if they could hold down food. Khan and Fletcher worked on providing a steady supply of food to the ward. Khan and Fletcher

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The symptoms weren’t always obvious. Ebola was a disease with different faces, and in its early phases it could look like malaria or dysentery. As Khan went on his morning rounds, he kept finding people who had the symptoms of Ebola. He ordered blood tests, and some of the patients tested positive, and were sent into the Ebola ward.

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work on constructing a plastic tent that had been donated to the hospital by Doctors Without Borders. Just as the structure was being finished, a rainy-season thunderstorm destroyed it. Khan and Vandi immediately set out to build a larger tent. In the meantime the Ebola ward got packed. Lina Moses was running around in flip-flops tending emergencies. She got too busy to take her malaria pills, and she broke with malaria. Shaky and feverish, Moses continued to manage the crisis center. Michael Gbakie and

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Triangle in ambulances, continued to find and bring in fresh Ebola patients. Tom Fletcher and Humarr Khan began to fear that they weren’t going to be able to stabilize Kenema Government Hospital. And then nurses who worked in the general wards began leaving their posts, becoming fearful that the virus was getting into the general wards. The general staff had started abandoning the hospital.

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this point Khan realized that he and his own staff in the Lassa program were getting cut off by the virus. The virus was driving away the hospital’s main staff, leaving Khan and his people increasingly exposed. The virus was out there and growing, and it was hitting the hospital harder and harder, and starting to erode the medical system in Kenema the

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things to do.” The nursing staff was abandoning the hospital, yet the general wards were still full of patients. Family members of the patients were taking over the care of their loved ones in the absence of nurses. The virus had gotten into the general wards. People were very, very scared. “Since most of the health workers

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The rest of the hospital might collapse, but Khan’s team had to hold its ground. Somebody in the room began crying softly. Other voices joined in the crying. Khan spoke over the crying. “This is our work to do. This fight is our fight now. We are working for our nation.”

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book,” Stephen Gire said. “The book is bound in covers and has an ISBN [International Standard Book Number] on it. It’s a short book, so a reader can easily digest it. You can find the book by its ISBN number, and that’s why the droplet is called a library. The books in the DNA library are bound so that the library can be put in a machine”—a genetic sequencer—“and the machine reads all the books.” The “books” of DNA letters were all sitting in one immense, jumbled pile, and what was between their covers was unknown. Although the droplet was just a spot of water with DNA in it, it held as much information as the books in fifty thousand Libraries of Congress. This shows the ability of life to store

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very small space. The library droplet contained fourteen images of Ebola virus, fourteen frames of a movie taken of the virus as it began to chain its way into the human species. The images were jumbled into tiny fragments and mixed together with vast amounts of other fragments inside the library droplet. The fourteen images still had to be found and pulled out of the droplet.

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thousand Libraries of Congress in the droplet, and thereby start developing an image of the shifting code of the Ebola swarm as it flowed through human bodies in West Africa. In Cambridge, at the logging

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The other reason Pardis Sabeti and Robert Garry couldn’t get help to Humarr Khan was because of a shortage of medical people who had training and experience at dealing with an outbreak of a Biosafety Level 4 hemorrhagic fever virus.

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There just weren’t enough knowledgeable doctors. Doctors Without Borders had taken the lead in crushing Ebola during past outbreaks. The Doctors knew how to set up an Ebola biocontainment ward and run it safely. They had biocontainment tents, they had spray pumps, laboratory equipment, generators, food, doctors, and robust supply lines, and they had a depth of operational experience with Ebola. And the Doctors were already stretched to their maximum. The medical world as a whole had no idea, no clue, how to stop an Ebola outbreak or how to safely handle patients infected with a huge, aggressive, Biosafety Level 4 virus.

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fluids, which got splashed and smeared all over the nurses’ protective gear. The patients did bleed from their gums, and their urine could turn bloody, but the nurses didn’t see nosebleeds. Of course there were expulsions of melena—hemorrhage—from the intestinal tract. Was there something different about this West African Ebola? Was it really the same as classic Zaire Ebola?

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About an hour after Dr. Azziz left the ward, at about seven a.m., Nyokor got out of bed and walked to the toilet at the end of the ward. While he was in the toilet, he had a bout of diarrhea—his constipation had suddenly ended. While he was in the toilet he collapsed and fell, and hit his head on something. Nurse Lucy went into the toilet to assist him and discovered that he was bleeding from a wound in his scalp. She cleaned the blood from the laceration on his head and got him back into bed. An hour later, Nyokor went into sudden shock and died abruptly.

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Lucy May left the Annexe ward and went home to get some rest. She needed her rest, because she was pregnant and her baby was due soon.

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United States it would be a national emergency. It was the same at the Kenema hospital, a national emergency, and the nurses knew this. It’s why Princess Gborie had reported to work that morning, though by all accounts she was deeply afraid of the virus.

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people that gathered in front of the Ebola ward every day. Some of the people in the crowd had Ebola and were vomiting. He spoke to her about the flip-flops, and he was upset. “You are insane to wear those! You must wear rubber boots!”

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reason for facing backward as you exit the Hot Lab is so that you can watch to make sure you aren’t accidentally dragging any contaminated material or object out of the lab, anything that might have somehow gotten stuck to your body.

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Ebola ward, doing what he could. He was distressed by the situation, and disturbed by what he felt were serious lapses of biosafety. The nurses were supposed to spray their hazmat suits with bleach before they took them off, but often the bleach sprayer was out of bleach, or the nurses didn’t bother to spray themselves.

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future, and that his visions were significant and powerful. Wahab paid house calls. If you wanted to know your future, he would show up at your door, if he chose to. He didn’t charge money for his visions, he gave them for free, and only if visions came to him.

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Now, he began walking around on the paths outside the hospital buildings, and he lingered at the maternity ward. “Oh!” he shouted in a piercing voice that carried into the maternity ward. “Oh! A nurse has died here!” (He was speaking in Krio—his words are an English translation provided by a member of the hospital staff who heard Wahab speak.)

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“Three nurses will die!” Wahab shouted. “One nurse has already died! Two more will die! Three nurses will die! This cannot be changed!”

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“Even if you can make that ceremony or you don’t do it, three nurses are going to die,” he shouted. “But if you don’t do that, if you don’t make the ceremony, many nurses will die! You must do a sacrifice and prayer!” Then, as suddenly as he had appeared, the boy slipped out through the hospital gates and disappeared into the city.

#africanstyle

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The virus typically kills the baby inside the womb, and triggers flooding hemorrhages from the birth canal as the baby is being born. The baby, itself infected with Ebola, is either stillborn or dies shortly after birth. This aspect of Ebola disease has been

#ebola#sop

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Lassa and Ebola produce similar effects in pregnant women: profuse hemorrhaging, death of the baby, death of the mother. Both viruses are nearly always lethal to the baby and typically lethal to the mother.

#ebola#sop

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For reasons that aren’t clear, the Lassa rescue procedure seems to increase a Lassa-infected pregnant mother’s chances of survival dramatically—giving her perhaps as much as a fifty-fifty chance at

#interesting

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The baby could be born naturally, and it might have chance of survival. Auntie decided to wait, not make a decision yet. She would not abort Lucy

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the sight of the stillborn child and the blood and fluids in the cot and all over themselves, the three nurses would have received visual confirmation of their fears that they themselves would get infected by this procedure. There was too much fluid and blood, the virus was everywhere, all over them, all over Lucy, coming out along with the child.

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There was no oxygen in the ward, no way to assist her breathing. At 9:15 p.m. Lucy lost arterial blood pressure and went into shock. Her blood pressure collapsed, her heartbeat became irregular, and at about 9:30 p.m.

#ebola#sop

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When it was clear that she had passed, the three attending nurses burst into screams, and their screams turned into roars of agony. The sounds came out of the Ebola ward and drifted across the hospital grounds in the darkness, frightening people all over the hospital. Fifty yards down the hill from the Ebola ward, Nadia Wauquier was working inside the Hot Lab in a moon suit. She heard the nurses’ cries and knew that something terrible had happened in the Ebola ward.

#dark

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nurses’ tears. Eventually Auntie went to the decon area and removed her bio-hazmat suit, which was smeared with birth fluids and blood. There was a bleach sprayer in the decon area. No one knows if it contained any bleach that night. The sprayer was often empty or not used, and a shortage of bleach had developed at the hospital. No one knows whether Auntie sprayed her suit before she took it off. Underneath she was wearing her usual starched white outfit, which was now completely soaked with sweat. Her brother, Mohamed Yillah, was waiting for her.

#risk

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started his motorbike, and she climbed onto the seat behind him and wrapped her arms around him, and he drove her home. He caught it, too. The next afternoon,

#risk

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Wahab the Visioner walked swiftly around the hospital grounds, agitated and shouting, driven by a vision of the future that seemed to torment him like stinging flies. “Oh!” he cried in a piercing voice. “Oh! You did not make enough sacrifice! You did not make enough sacrifice!” The nurses’ ceremony had failed, he shouted. Lucy May had been one of the three nurses who had been fated to die. Now many more nurses were going to die.

#crazy-vision

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The future could still be changed. Wahab’s voice carried into the main wards of the hospital, and he may have gone inside the wards and prophesied directly at nurses and patients—those who were still left at the hospital. “For now,” he shouted, “you must sacrifice a candle. All living nurses must make this sacrifice. You must light candles all around the hospital compound. All the nurses must do this! If you don’t do this sacrifice a lot of nurses are going to die. Even an important doctor will die.” Abruptly the young man was gone.

#crazy-vision

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among them an important doctor would be among the dead. If Auntie Mbalu Fonnie couldn’t stop the virus no matter what risks she took, and if candle flames didn’t stop the virus, then there would be no way to stop it, no way at all.

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we are going to stop the next virus, it pays to study history. There is much to be learned by looking at the people who engaged with Ebola during its first known encounter with the human species. We can study their lives and deaths, and we can watch what they did as they confronted the unknown. We can watch the moves they made as they engaged with the virus—and the moves the virus made in response. We can learn their secrets.

#lesson

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