Hell and High Fever

After he finished bleaching his medical space suit and left the Ebola ward’s doffing station, Dr. Lewis Rubinson began to assess his risk of exposure as he walked up the hill toward the World Health Organization’s office in Kenema, Sierra Leone, last September. The needle that pricked his thumb had been stuck in a plastic, intravenous bottle hanging above a young woman’s bed. Rubinson had accidentally poked himself as he’d disposed of the syringe and repositioned it in his hand. The needle had penetrated deep into his skin, he realized, when he felt blood oozing underneath the two pairs of gloves he was wearing.

“Not good,” he said to himself.

Undoubtedly, a local nurse had inserted the syringe into the side of the IV bottle to create a flush—a practice that isn’t actually effective, but nonetheless common in West Africa. Clean needles were typically used, Rubinson knew, but this patient had arrived in Kenema by ambulance with her IV already started. It was impossible to rule out that the needle had been previously used to draw blood.

There was no sign of blood on the syringe, however. If anything, Rubinson, who directs the Critical Care Resuscitation Unit at the University of Maryland’s R Adams Cowley Shock Trauma Center and has biosecurity and biodefense experience, figured there was a greater chance that the needle had pushed contaminated material from his protective gloves into his bloodstream. He recalled that he’d helped a confused Ebola patient back to bed shortly before he’d jabbed himself.

As he made his way to the WHO’s office, he calmly talked himself through all the possibilities. It’s not like he hadn’t known the risks before he arrived in West Africa. Where Rubinson was stationed in Sierra Leone, some 30 health care workers had already been infected with the disease, including 19 fatally. In fact, the physician he replaced had contracted the virus and become critically ill. And he’d also witnessed more than a hundred torturous and lonely patient deaths in the Ebola wards and tents at the Kenema Government Hospital during his three weeks.

In the end, he concluded his likelihood of contraction was low—a 10-percent chance, at most. Nonetheless, he knew he had met the criteria for a high-risk exposure. One day before his mission was scheduled to end, he was evacuated back to the United States. It was not where he wanted to be.

“What I felt, more than anything, was disappointment, and shame and embarrassment. I wasn’t going to complete the mission.”

“What I felt, more than anything, was disappointment, and shame and embarrassment,” says Rubinson, who is thoughtful and engaging, describing the complex set of emotions he was dealing with. “You build strong relationships in that type of environment in a short period. I wasn’t going to complete the mission and the team coming in wasn’t fully prepared to take over. I also understood that the tens of thousands of dollars it would cost to evacuate me—because of my privilege—could save a lot of lives in Sierra Leone.”

What Rubinson didn’t feel was any regret about volunteering for duty in the center of the most deadly contagious disease outbreak in decades, in a country still reeling from the effects of a civil war.

“If not me, with my background,” he says, “then who?”

Dr. Lewis Rubinson, director of the Critical Care Resuscitation Unit at the University of Maryland’s R Adams Cowley Shock Trauma Center, in Kenema, Sierra Leone. Courtesy of Andres Kelto/NPR

Between 1976, when the Ebola virus was first identified, and 2012, there were two-dozen outbreaks, totaling roughly 1,600 reported deaths. Those sporadic occurrences of the brutal hemorrhagic fever (accompanied by internal bleeding) had essentially been limited to rural communities in Sudan, Gabon, Uganda, and the Democratic Republic of the Congo, in places with little or no running water or electricity, such as the village of Yambuku, near the Ebola River, where the disease takes its name. In other words, there had been nothing remotely close to the recent eruption, which spread for the first time to large cities and urban slums, causing more than 28,000 reported cases and more than 11,300 deaths to date.

The good news, if anything associated with Ebola can be called good news, is that, compelled by the scope and urgency of the tragedy, several promising FDA vaccine trials are now underway. And, perhaps equally significant, policymakers and critical-care experts, such as Rubinson, are addressing the public health challenges that came to light during the viral outbreak—not the least of which were the communication failures that fed a widespread panic around the world. It’s also important to note that while the worst of the crisis passed at the start of this year, handfuls of new cases continue to come out of Guinea and Sierra Leone on a weekly basis.

“The Ebola outbreak in West Africa was a historic event,” says Dr. Myron Levine, founding director of the University of Maryland’s Center for Vaccine Development, which works in collaboration with the Ministry of Health in Mali, the Malaria Research and Training Center at the University of Bamako, and the National Institutes of Health [N.I.H.]. “If it were a movie or novel, what took place would seem preposterous. It shook the entire global health community to its core.”

The first hint Rubinson caught of the growing fear gripping the United States came while he was aboard his Kenema evacuation flight, which had planned to refuel in the Azores, the Portuguese islands in the North Atlantic. “The U.S. Air Force didn’t want us to land there,” Rubinson recalls. “Then, they told us we could, but we were not to open the door of the plane. ”

A month before Rubinson left for Sierra Leone, in August of 2014, Emory University had quietly, and successfully, treated two Americans, an aid worker and a physician, who had been working in Liberia. A few weeks later, an American doctor was admitted to Emory, and another to the Nebraska Medical Center. But the burgeoning epidemic was only beginning to garner serious media attention when Rubinson took off for West Africa. At that point, no one had contracted the disease on U.S. soil. Still, during Rubinson’s tour in Kenema—where he remained in something of an American media blackout, without so much as reliable phone service—concern mounted in the U.S. and elsewhere alongside the skyrocketing death tolls.

Rubinson was asymptomatic as he hustled through Ebola checkpoints on the long drive out of Kenema to Freetown, where he boarded the evacuation plane a day after his needle stick. Indeed, he wouldn’t have been contagious at that point even if he had contracted the virus, which has an incubation period of nine to 11 days. But his simple existence inside the aircraft had clearly caused alarm among the leadership at the U.S. Air Force base.

Although Rubinson had concluded his overall risk of exposure was low, as soon as he climbed on board, he signed a consent form and was injected with an experimental vaccine, which had been rushed from Emory, with the hurried approval of the N.I.H., and flown from Georgia to Freetown—all as a precautionary measure.

“I watched the hysteria play out on cable tv from inside the isolation unit,” rubinson says.

“I talked to Lewis before he went to Sierra Leone, while he was working in Kenema, after his needle stick, and was in contact with him as he was driving to Freetown,” says Dr. Tim Uyeki, the current Centers for Disease Control Ebola response clinical team leader and friend of Rubinson’s. “Forty-three hours after his needle prick, he became the second human trial for the investigational vaccine. Twelve hours later, he was just beginning to experience symptoms associated with the vaccine—which mimic those of Ebola—as he was arriving at N.I.H. [the National Institutes of Health in Bethesda].”

When Rubinson landed at the Frederick Municipal Airport on the afternoon of Sunday, September 28, he was met by the national media and a film crew, as well as an ambulance and multiple Maryland State Police vehicles for a siren-led escort down I-270. His name was not released publically because, among other reasons, Rubinson was trying to protect his then-6-year-old daughter from scrutiny (and concern), as he headed into isolation. He hadn’t as much as told her he was going to West Africa to treat Ebola patients. “I didn’t want her to learn from someone at school where I was or, worse, for her to be singled out because I was in an N.I.H. isolation unit.”

A few hours before, by terrible coincidence, a Liberian native named Thomas Duncan, who’d recently flown into the U.S., had sought medical attention at the Texas Health Presbyterian Hospital emergency room, experiencing nausea, dizziness, and fever. Two days later, the CDC announced Duncan, who later died, had the Ebola virus. Not long afterward, Nina Pham, a 26-year-old nurse who had treated Duncan in Texas, tested positive for Ebola, becoming the first person to contract the disease in North America. Like Rubinson, Pham was flown to Frederick and taken to N.I.H for isolation and treatment. (A second nurse at the same Texas hospital also tested positive for Ebola a few days later.)

“I watched the hysteria play out on cable TV from inside the sealed isolation unit,” says Rubinson. It was a tense several days in the isolation unit as Rubinson battled through Ebola-like symptoms, including a 103-degree fever, chills, headache, and nausea, checking his eyes in the mirror for the appearance of telltale blood each time he got up. But he was comforted by what Uyeki had told him: that his body’s immune response to the experimental injection would mimic the symptoms of Ebola. Ultimately, it was confirmed that he had never contracted the disease. (Rubinson later documented his experience as a vaccine patient in a paper co-authored with Uyeki, among others.)

He was allowed to spend the last 10 days of his 21-day quarantine at his home in Roland Park.

“Patient zero” of the current outbreak, investigators believe, was a 2-year-old boy from a remote area in the Guinea forest, who most likely became infected in December 2013 after playing in a hollow tree that housed a bat colony. Within days of his death, his 3-year-old sister and pregnant mother were dead as well. Early on, local hospitals became inadvertent incubators of the virus, as health care workers, nurses, and doctors, who believed they were dealing with cholera or Lassa fever—a much less deadly hemorrhagic virus prevalent in the region—contracted Ebola after treating patients. The first case across the border in Liberia was confirmed a few days after the WHO officially declared an Ebola outbreak in late March of 2014. By June, the virus had reached Monrovia, the capital of Liberia, and by July, Kenema and Freetown, the capital of Sierra Leone.

“Guinea, Liberia, and Sierra Leone, these countries physically share borders and the population started to migrate across from Guinea to Liberia, from Guinea to Sierra Leone as the crisis occurred,” says Levine, noting Maryland’s malaria and cholera research partnership has since launched Ebola vaccine trials in West Africa. “When the WHO announced in August that the conditions for a Public Health Emergency of International Concern had been met, that was a big thing. That’s very rarely invoked.” By October, nearly 30 countries had imposed blanket, or near-blanket, travel restrictions to and from affected countries in West Africa.

Ebola spread so rapidly, in part, because its symptoms are similar to those of other viral diseases—fever, fatigue, stomach pain, vomiting, and diarrhea. Once a person contracts the Ebola virus, it can be passed to others through contact with the infected individual’s blood and bodily fluids. The risk of transmission becomes greater when a person is severely ill and even shortly after death—of particular concern in Africa, where traditionally quick burials include the touching and kissing of the departed.

“One burial ceremony in Guinea was subsequently linked to 85 confirmed cases,” says the CDC’s Uyeki.

Before traveling to Sierra Leone, Rubinson had never seen an Ebola patient, but he had previously served as acting chief medical officer for the National Disaster Medical System and did have experience responding to the 2009 H1N1 swine flu pandemic. As an academic fellow at The Johns Hopkins University, he’d also studied SARS, the severe acute respiratory syndrome outbreak that first was reported in China. So, when the Society of Critical Care Medicine put out a call for doctors willing to travel to West Africa, he applied. “By the time I went, people I knew had gone and come back and I understood that the resources in Kenema were overwhelmed.” When he arrived, there were 120 to 125 patients at the hospital and not a single physician doing primary care. “There’s a difference between understanding something in an academic sense and seeing it on the ground,” he says.

“This is a country with a population of 6 million, a GDP of $5 billion, a life expectancy of 46, and a literacy rate of 48 percent,” Rubinson says. “Once I got there, I thought, ‘How the hell do we stop the spread? There is no real diversion of sewage. Is there enough potable water? How do we educate the people about contamination? Is there the funding to do the work?’”

There was also the immediate problem of being limited by working in a hot suit with no air conditioning. Rubinson and his colleagues could only withstand the heat and humidity inside their protective gear for two-hour shifts—one in the morning and one in the evening. Complicating matters, some people who suspected they might have Ebola hesitated to seek medical attention because of the friends and family members they saw dying under care of straining hospitals. Even with treatment, the disease has a 50 to 60 percent fatality rate in West Africa. By contrast, of the 11 Ebola patients treated in the U.S., two died.

By the start of this year, West African governments and groups such as the WHO and Doctors Without Borders, which has a long history of dealing with Ebola, managed to contain the crisis through various efforts, including tracing and isolating the contacts of those infected by the disease. But future outbreaks remain a risk as long as the disease lives in animals with which human beings potentially have close contact.

Still, for all the real, and, in many ways, unprecedented, tragedy around the outbreak, viral experts such as Rubinson, Levine, and Uyeki are quick to point out that a genuine Ebola outbreak in the U.S. remains highly unlikely and far from their worst fear. Ironically, the exotic nature of the disease probably drove the hype around the virus as much as its deadly attributes.

“This was the 25th outbreak of ebola. it’s not going to be the last viral Disease outbreak.”

First, viral experts seem assured that a successful vaccine will emerge, now that there is economic incentive to take one to market. (The one given to Rubinson is one of a number of candidates seeking approval.) Secondly, despite how fast the disease spread in West Africa, once properly diagnosed, avoiding exposure—given that it requires physical contact with bodily fluids—is easier than avoiding exposure to other potentially deadly, respiratory viruses.

It’s worth highlighting that the seasonal flu is actually much more deadly. The CDC estimates that on average, 5 to 20 percent of the population in the U.S. contracts the seasonal flu each year, resulting in more than 200,000 hospitalizations from related complications. And annual estimates of flu-associated deaths typically range between 23,000 and 32,000 in the U.S.—despite the availability of vaccines.

And that’s not the worse of it. “From a global perspective, I am much more worried about airborne respiratory viruses entering the U.S. than Ebola, which are more of a concern because of the way they are transmitted,” says Uyeki. “There’s still no vaccine for SARS. No vaccine for MERS [Middle East respiratory syndrome],” both viral strains with significantly higher fatality rates than the seasonal flu. “The biggest worry is about a new influenza pandemic virus from an avian or swine source.”

Dr. Sharon Hrynkow, president of the Baltimore-based Global Virus Network, which was spun off the University of Maryland’s renowned Institute of Human Virology in 2011, says that the lesson from Ebola is that every country must be able to diagnose and address outbreaks as they emerge. “This was the 25th outbreak of Ebola and it is not going to be the last outbreak of a viral disease,” Hrynkow says. “The main message is that we need medical virologists in every country because we need great diagnostics so we can distinguish one disease from another. The time it takes to send out samples from one country to another is the time it takes for a disease to spread from one country to another in the global community.”

In the event of any near-future Ebola outbreak, Rubinson believes proper identification procedures and training can protect the emergency room staffs at the roughly 6,000 hospitals in the U.S. and that specially designated regional centers should handle isolation and treatment efforts.

Dr. Myron Levine, director of the University of Maryland’s Center for Vaccine Development since its inception in 1974.

The harder task regarding viral outbreaks going forward may be combatting the misleading information and click-bait grabbing headlines, such as “You Are Not Nearly Scared Enough About Ebola,” which appeared atop a Foreign Policy magazine story last year.

Today, a year after he returned from West Africa, Rubinson is able to dissect the clinical and public health aspects of his work, but still appears to be in the process of resolving some of the more personal issues.

The ethical dilemmas alone in such an environment—Should health care worker safety be given priority over that of patients? Should the sickest or youngest patients be treated first? Or the most likely to survive?—can be very difficult to navigate and accept. On top of that, the shame and guilt of being evacuated while others were left behind lingers, as do other memories from Sierra Leone.

“As a doctor, one of the hardest things that you go through is watching a patient who has progressed to a point that is irreversible, where treatment no longer has a chance to make a difference,” Uyeki says. “I know Lewis went through that. We all handle that differently, but it affects all of us and it hurts all of us.”

Since returning home, Rubinson has heard people express their opinions that it was wrong for him and other medical professionals to go to West Africa, and potentially carry the Ebola virus with them back into this country, which he admits has been disheartening. “We didn’t come back to hide what we did,” he says.

Similarly, knee-jerk political reactions to implement mandatory quarantines for health care workers who traveled to West Africa—such as those issued by the governors of New Jersey, New York, Maine, and Illinois—were discouraging. “It’s already difficult to leave your life and your work on short notice for three to four weeks,” Rubinson says. “To automatically tack on another three weeks on top of that, without scientific basis, is going to become problematic for people to respond in these situations. It’s counter-productive.”

At the University of Maryland, however, the reception was much different.

“I wrote to everyone on staff when he came back to make sure they put their hand out and thanked him for his courage and sacrifice,” says Maryland Shock Trauma Center physician-in-chief Dr. Thomas Scalea, who recruited Rubinson to run the Critical Care Resuscitation Unit. “It’s hard to overestimate the courage it took to uproot his life, leave his daughter behind, and put his own life in very real danger.”

Despite everything that happened, Rubinson says he would do it again.

“I still have my own feelings of disappointment because I take professional pride in safety. I also have feelings of frustration around the international response,” he says. “But I’m incredibly glad I did it. I got to witness a lot of what the rest of the world didn’t see and learn from that. I’m most happy about the people I saw survive.”