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 Sheik Umar Khan was a hero in his small West African country for
leading the fight against the worst ever outbreak of the highly
contagious hemorrhagic fever, which has killed 1,427 people mostly
in Sierra Leone, Liberia and Guinea.
When Khan fell sick in late July, he was rushed to a treatment unit
run by Medecins Sans Frontieres (MSF) where doctors debated whether
to give him ZMapp, a drug tested on laboratory animals but never
before used on humans.
Staff agonized over the ethics of favoring one individual over
hundreds of others and the risk of a popular backlash if the untried
treatment was perceived as killing a national hero.
In the end, they decided against using ZMapp. Khan died on July 29,
plunging his country into mourning.
A few days later, the California-manufactured pharmaceutical was
administered to U.S. aid workers Kent Brantly and Nancy Writebol who
contracted Ebola in Liberia and were flown home for treatment. It is
not clear what role ZMapp played in their recovery but the two left
hospital in Atlanta last week.
Khan is among nearly 100 African healthcare workers to have paid the
ultimate price for fighting Ebola, as the region's medical systems
have been overwhelmed by an epidemic which many say could have been
contained if the world had acted quicker.
In their village of Mahera, in northern Sierra Leone, Khan's elderly
parents and siblings asked why he did not get the treatment. Khan
saved hundreds of lives during a decade battling Lassa fever - a
disease similar to Ebola - at his clinic in Kenema and was Sierra
Leone's only expert on hemorrhagic fever.
"If it was good enough for Americans, it should have been good
enough for my brother," said C-Ray, his elder brother, as he sat on
the porch of the family home. "It's not logical that it wasn't used.
He had nothing to lose if it hadn't worked."
Doctors who knew Khan and who were involved in the difficult
decision, however, said it was based on sound ethical reasoning.
Ebola, which is passed on by direct contact with the bodily fluids
of infected persons, strikes hardest at healthcare providers and
carers who work closely with patients.
Victims suffer vomiting, diarrhea, internal and external bleeding in
the final stages of the disease, leaving their bodies coated in the
virus. To treat the sick, doctors require training and protective
clothing, both of them scarce in Africa.
The outbreak - the first in West Africa - was detected five months
ago deep in the forests of southeastern Guinea. But it was not until
Aug. 8 that the World Health Organization declared an international
health emergency and promised more resources.
By decimating healthcare staff in countries that had only a few
hundred trained doctors before the outbreak, Ebola has now left
millions vulnerable to the next crisis, experts say.
"Dr. Khan knew the risks better than anybody ... but if you work for
months in overcrowded facilities, 18 hours a day, anyone will make a
mistake," said Robert Garry, professor of microbiology and
immunology at Tulane University in New Orleans, who worked with Khan
for a decade.
"The whole international community needs to look back and say we
dropped the ball. We should've reacted faster to this."
TENSE ATMOSPHERE
To many in his impoverished country, Khan was a saviour for his
pioneering work with Lassa fever, a disease endemic to the jungles
of eastern Sierra Leone that kills 5,000 people a year. When Ebola
struck, he became a figurehead for that fight, too, hailed by
President Ernest Bai Koroma as a "national hero".
Doctors involved in treating Khan were aware that - given sporadic
violence against healthcare workers by a frightened local population
- a misstep could prove costly.
"Now you can look back at that and say it was a mistake," said
American doctor Daniel Bausch of Tulane University, who worked with
Khan and advocated giving him ZMapp at the time.
"But there was a very tense atmosphere on the ground," he said. "If
he had died from the drug, or even if it was perceived that he had,
it could have had dangerous ramifications."
Doctors also had ethical concerns about giving Khan priority
treatment that hundreds of other infected people could not receive,
since only a few doses of ZMapp had been manufactured.
The president of Medecins San Frontieres - which has spearheaded the
response to Ebola at clinics in Sierra Leone, Guinea and Liberia -
said its doctors could not sanction use of a drug on Khan whose
effects were unknown.
"We didn't know what the consequences would be. We didn't know how
sick he was and we didn't know how efficient it would be," Joanne
Liu told Reuters.
Khan, who had initially appeared to be recovering, was never told
that the drug was available. Two weeks after his death, the World
Health Organization approved the use of experimental drugs to tackle
Ebola, on Aug. 12.
However, the manufacturer of ZMapp, California-based Mapp
Biopharmaceutical, said supplies of the drug are exhausted after the
last doses were used in treating three African healthcare workers in
Liberia last week. Like the two Americans, they are also recovering.
Supplies of trial vaccines to prevent people contracting the disease
are also very limited. With only 1,590 deaths from Ebola in the four
decades that have passed since the virus was first isolated, all of
them in poor African countries, drug firms have had little incentive
to pursue research into the disease.
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Drug companies including GlaxoSmithKline are now fast-tracking
vaccine trials in humans, amid fears that Ebola could be spread
beyond Africa by air travel, after a U.S. citizen died in Nigeria
after flying from Liberia.
"We need to get healthcare workers vaccines. They are in harm's
way," said Robert Garry, the main investigator at Viral Hemorrhagic
Fever Consortium, a partnership of research institutes. He said the
outbreak would last at least six months.
"We need a lot more people to bring this under control. We haven’t
seen the worst of this yet."
"WHO WILL FILL MY SHOES"
Khan knew from the first his work at the Kenema clinic would be
dangerous. When he took over as head doctor there in 2004, his
predecessor had bled to death from Lassa fever in the same ward.
But after 11 years of civil war, there were few others who could do
the job. The last but one of 10 children from a humble background,
Khan always wanted to be a physician like his childhood hero Dr.
Kamara, who ran a clinic in Mahera.
Determined to enter Freetown's medical school COMAHS, Khan persisted
despite being initially rejected. When he graduated, his father was
too ashamed to visit this preserve of his country's elite and
listened to the ceremony on the radio.
"When the name Dr. Sheik Umar Khan was called out by the dean of the
faculty, my father broke down in tears of joy," Khan's sister
Mariama recalled.
An extrovert and joker, Khan threw himself into his work in Kenema,
a diamond-trading hub home to 130,000 people. His wife divorced him,
complaining he only had time for his patients.
When Ebola struck, Khan converted the bungalows of the clinic into
an Ebola treatment center, erecting a makeshift tarpaulin ward
outside with 50 beds in three rows. With no proven cure, doctors
simply tried to keep patients hydrated and free from other diseases
as Ebola attacked their immune system.
Though he feared for his life, he refused to abandon the
understaffed clinic, even as nurses there began to fall sick.
"If I leave, then who will come and fill my shoes," he told a friend
from medical school, James Russel.
Outbreaks in Central Africa lasted six to eight weeks, so when
infections ebbed early in the epidemic, many assumed the worst had
passed. It turned out to be a lull as relatives hid victims rather
than going to hospitals regarded as death traps and a massive second
wave of infection caught governments and international aid donors
off guard.
One of Khan's biggest challenges was resistance from local people,
terrified of the medics in their white bodysuits and masks. A crowd
attacked the Kenema facility, enraged by a rumor of cannibalism
there. Several patients fled, spreading infection even wider.
"My biggest problem ... is getting people to accept the disease," a
frustrated Khan told Reuters in June.
The first person infected in Sierra Leone was a "sowei" - a tribal
healer. She claimed to have the power to treat Ebola and had
attracted sick people to visit her from Guinea. Traditions of
washing the dead helped spread the disease. Several women from
neighboring towns were infected at the sowei's burial.
Already thinly staffed, the clinic was sapped by resignations and a
strike after three senior nurses died. Khan was compulsive in
checking his protective gear before entering the ward, using a
mirror he called his "policeman".
"I'm afraid for my life because, I must say, I cherish my life," he
said.
Bausch, sent by the WHO to Kenema in July to help train staff, said
Khan had appeared worn down. Bausch had hired Khan to work at the
Kenema clinic in 2004 but was so alarmed by the understaffing there,
he had wondered if it should be shut down.
"It's one thing for a foreign doctor who comes in for three weeks.
But if you're Dr. Khan, head of the ward, it never stops," Bausch
said. "Anyone would get infected."
Khan's death sent shockwaves through Sierra Leone's small medical
community of less than 150 doctors for its 6 million people - one of
the lowest ratios in the world. Sierra Leone has one doctor per
45,000 inhabitants, according to the WHO, compared to a doctor for
every 410 people in the United States.
Other senior medical staff in the country have since died and the
staff at Kenema has been decimated.
"Once this nightmare is over, who in these countries will want to
work treating patients with hemorrhagic fever?" said Bausch. "If it
was hard before to get healthcare workers to do it, it will be even
harder now."
(Editing by Pascal Fletcher and Anna Willard)
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