The Airplanes That Rescue Ebola Patients
This story was published in June 2019, it's been updated following Kalitta Air's evacuation of Americans during the Wuhan coronavirus outbreak.
December 21, 2018
Nyankunde, Democratic Republic of the Congo
Nyankunde is far too beautiful of a town for the atrocities humans have committed in it. Surrounded by savanna, it sits lush and pastoral under a clutch of hills that look like green knuckles. It is a hospital town, known throughout the country for both Congolese and international specialists. It was a hospital town in 2002, when a militia supported by a displaced tribe that had not been allowed to use the hospital raced down from the top of the hill and murdered roughly 3,000 civilians, many of them doctors and patients, in what became the single largest day of death in the Second Congo War, a nine-country conflagration that lasted from 1998 to 2003. As the violence seethed, the bricks of the hospital came down. Many of the buildings became roofless husks, toothless mouths, ruins. And even then, Nyankunde was a beautiful town.
By 2004, the hospital had returned. It now has several new buildings and new medical equipment provided by humanitarian organizations such as Samaritan’s Purse. It is staffed by doctors like Patrick LaRochelle, who first visited the Congo just before he started medical school, heard about the massacre, and thought to himself: I never, ever want to live in the Congo. But LaRochelle and his wife are religious people, good people, who felt called by God to practice medicine in an underserved community. LaRochelle’s wife is a nurse practitioner who grew up doing humanitarian work in Haiti. After LaRochelle completed his residency, they applied to a program with World Medical Mission, part of Samaritan’s Purse, which listed the hospital in Nyankunde as a top option. They thought and prayed and asked friends for advice, and, well, here they are.
LaRochelle—sinewy, bespectacled, unassuming—was leaving the hospital for the day when a maternity nurse told him a woman had just been transferred from the maternity ward to the Intensive Care Unit and was having trouble breathing. Because of an Ebola outbreak that had started in the nearby province of North Kivu in August, LaRochelle was supposed to wear gloves with every patient. The hospital had received shipments of thermometers and protective clothing and were paying screeners to monitor the entrances, where they kept bottles of bleach just in case. But LaRochelle was about to leave on his walk home and, after following protective protocol for five months with no actual Ebola patients, he had a bit of vigilance fatigue. He walked up to the woman and listened to her lungs through his stethoscope.
LaRochelle had never seen a case of Ebola before, but he put the signs together quickly: The woman was agitated. She was bleeding from locations where doctors had attempted to start IVs. Her eyes were red in the way he had seen in photographs. She didn’t have a fever, but her fetus had died, which was a horrible, classic presentation of the disease. He asked a nurse to find out where she was from. One of the woman’s family members replied that she was from Otomaber, a village where new cases of Ebola had been cropping up.
One of the screeners at the gate should have realized what illness this woman had and taken her directly into the new isolation area they had built since the outbreak began. In fact, she had been stopped. But the woman was the daughter-in-law of the hospital’s chauffeur, and he had either not realized, or been so concerned for her, that he convinced the screeners that she was not a safety risk. When the woman was transferred from the maternity ward to the ICU, which is in a different building, none of the suspicions came with her. Now, LaRochelle was treating her with his bare hands.
Later, LaRochelle would hear that you’re considered a high-risk exposure in the United States if you touch an Ebola patient within the last 24 hours of their life.
He had treated this woman within her last four.
Four and a Half Years Earlier
July 26, 2014, was a Saturday, and Dent Thompson was five days deep into a 10-day vacation at his second home, on Beech Mountain in North Carolina. The place could be on a summer-camp brochure, a Swiss-style chalet situated on a 4,500-foot ridgeline with a 100-mile view into the shaggy blue forests of the middle Appalachians. Thompson had just settled in on the back deck with a Bud Light and a magazine when his phone rang. Area code 202. Washington, D.C.
On the other end of the line was the no-nonsense mid-Atlantic voice of William Walters, the managing director of operational medicine for the U.S. Department of State. Walters had been on the opposite of vacation for the past 24 hours, organizing the evacuation of some 150 people from the U.S. embassy in Tripoli because of violence in Libya. The State Department hadn’t wanted a repeat of Benghazi, but Walters had missed his wife’s birthday, which he didn’t expect she’d forget for some time.
Walters had slept for just two hours before the latest problem appeared. “Do you think the system you have would work for Ebola?” he said.
Thompson and Walters had only met about six months or so before that day, when the State Department had worked with Phoenix Air, the company Thompson managed, to prepare an air-ambulance service plan for the Sochi Olympics. If a dignitary had suffered some kind of medical incident at the games, the last thing the U.S. government wanted was a military plane swooping in and creating unsettling optics. Instead, they would call Phoenix Air, a small, independent flight carrier with a couple of air ambulances.
Phoenix Air itself had been around since the early 1970s, when Dent Thompson’s brother Mark had started it as a skydiving school after completing his tour of piloting helicopters in Vietnam. Over the intervening decades, the airline had evolved from its original charter into the business of doing “difficult things.” These were, as Dent says, aviation tasks so complex, paperwork-intensive, and/or unenviable that, once you’d established yourself as the only airline willing to do them, you could have all the contracts you wanted.
Dent Thompson and his brother Mark had grown up in Atlanta, so Mark had launched the airline out of nearby Cartersville airport, an ambitious name for a single asphalt runway in a town where every waitress knows you want an Arnold Palmer with your burger, easy on the tea. Dent was on vacation from Cartersville right now, although it was starting to feel less like a vacation and more like a bad dream you’d have after reading Stephen King’s The Stand. Dent didn’t know any medical facts about Ebola. He just started free-associating the phrases he’d seen on TV: It was the plague. You bled out of your eyeballs. Your internal organs liquefied.
Walters told Dent what they had going on up there, which was that two humanitarian medical workers helping out with the Ebola crisis in Liberia had come down with it. Their names were Kent Brantly and Nancy Writebol, and while everyone wanted to get them home, they had no idea how to do so safely. “The general dogma was, you don’t bring the zombie apocalypse to a city that doesn’t have zombies,” Walters says. But Walters had remembered what Dent had told him while planning Sochi, which was that as a joint consequence of ferrying Atlanta-based Centers for Disease Control luminaries around and being down for just about anything, Phoenix Air had developed a proprietary system for the transport of extremely sick people with extremely contagious diseases.
Dent looks like a painting of the fifth Earl of somewhere, down to the fluffy white hair and the peaked eyebrows. One imagines the arches of those eyebrows rose and rose as he contemplated the ponderous future of this particular difficult task. Dent told Walters that if he could bring all the top doctors in the U.S. government to Cartersville to tell him the system—which had never been used—would work, then they’d be willing to try it. Walters said he’d find out and call back.
For 15 minutes, Dent didn’t leave the porch. He drank his beer, and he looked out at the trees as gloom accumulated underneath them. Maybe it would all go away, he thought.
But then Walters was on the phone again: “I’ll have the world at your place on Tuesday.”
(Literally) Containing a Plague
In 2007, when the CDC first asked Phoenix Air to build the containment system, they had wanted it to transport patients with diseases like Avian Flu and Severe Acute Respiratory Syndrome, or SARS, back to the U.S. from international outbreaks. SARS can pass from person to person through droplets of moisture in the air. Anyone who’s ever caught a cold on an airplane can imagine how tough such a disease would be to contain in a closed cabin. To build the Aeromedical Biological Containment System (ABCS), Phoenix Air had employed CDC and Department of Defense engineers who handled samples of the most threatening diseases and chemicals on earth.
The ABCS consists of a frame of metal tubing contoured to fit inside an airplane’s fuselage, supporting a disposable plastic cocoon—a giant zippered sock made out of what looks like a double-thick shower-curtain liner. Everything inside the sock is disposable, including a stretcher, a bucket toilet, medical supplies, and leads for health monitors that can be operated by the medical crew from outside. To reach the patient area, a member of the medical team must walk from the sterile area of the plane through an air-lock-style antechamber, where she dons protective gear in a specific order with the help of a checklist and an advisor on the outside. A custom-built air pump creates a negative air pressure gradient from the main aircraft cabin, through the antechamber, and into the patient chamber. A virus floating in the air is pulled backward, into the sock’s figurative toes.
In most pressurized aircraft, the air you breathe is sucked in from the engines and introduced through vents all over the cabin. To maintain air pressure, some air leaves the cabin through a baffled outflow valve usually located near the cockpit. This outflow valve is on the opposite end of the plane from the toe of the sock, and would therefore act in opposition, airflow-wise, to the air pump protecting the crew from disease. In the modified corporate jet that flies the ABCS, Phoenix Air sealed the outflow valve up front and installed a new one in an unused luggage compartment in the rear, running the plane’s airflow backward, through the gradient of the sock, and out CDC-designed HEPA filters to the sky.
Back in 2011, when the ABCS prototype was completed, the plastic sock had been taken to Aberdeen Proving Grounds in Maryland, where government testers vibrated it on shake tables and brought it to 20 degrees Fahrenheit below zero. Phoenix Air itself had loaded it on a test aircraft with pilots wearing oxygen masks. They flew the system up to 45,000 feet and dumped the cabin’s air, as though a window had broken, then dived down to safety at 15,000 feet. The government had declared the ABCS safe and effective, but by then the SARS epidemic was over. Ten plastic kits sat unused in boxes in the back of a hangar, and Dent had mentioned them to the Department of State as almost an afterthought. (“Dent’s the best business development guy in the world,” Walters says of his targeted storytelling.)
In 2014, Dent returned from his vacation immediately and collected his medical staff, among them a mountain-biking emergency physician named Michael Flueckiger, who had worked at Atlanta’s Piedmont Hospital for 24 years and helmed the ER for two, and a genteel-accented registered nurse named Vance Ferebee, who, by 2007, had spent 22 years flying rescue in helicopters. Two days later, in a hangar break room complete with a kitchenette and several vending machines, they were joined by some 15 doctors and scientists from the CDC, the U.S. Department of Health & Human Services, the military, the National Institutes of Health, and the U.S. Department of State.
The officials sat at round cafeteria-style tables, as if it were lunchtime in junior high. Someone had the president on the phone. They decided Brantly and Writebol’s fate as a show of hands, and it was unanimous. Ebola is a fairly weak virus: It cannot move from person to person through the air like SARS can. It transmits only through bodily fluids. The ABCS was overkill. They would try it.
Ferebee and two other medical officers boarded a flight to retrieve Brantly two days later. They flew to Liberia and loaded the sick doctor exactly according to plan. And then everything went nuts.
Both Brantly’s destination hospital at Emory University and the ambulances that would transport him there had previously practiced what would happen if Phoenix Air landed with a highly infectious patient. They just hadn’t counted on it being Ebola, a virus uniquely capable of scaring the hell out of everyone. The nonmedical staff at Phoenix Air revolted first. Emory hospital had to have a sit-down hash-out in an auditorium. The national news waxed hysterical, with television stations camping out in Cartersville in their trucks with their broadcast antennas. One of Phoenix Air’s medical directors was forbidden to attend sporting events at his kids’ high school. Flueckiger had to lie to clinics when they asked if he’d been to any of the Ebola-stricken countries, to avoid getting quarantined.
Above that, the international politics were immense. All Dent could think was that there was no way this situation ended well. What if insurance companies asked them to ferry only certain people back? What if France asked Phoenix Air to bring back one doctor and the U.K. asked them to bring back another doctor and they had to choose? They had one plane. They were a private company. What the hell were they doing?
Dent asked the public affairs officer at the CDC what to do about the media, which led to a press conference at which reporters were allowed to see the equipment and ask any questions they wanted. Then, once Phoenix Air had completed a turnaround trip to deliver Nancy Writebol, William Walters drew up a contract that made Phoenix Air an official provider for the U.S. Department of State, which would make all the life-and-death decisions itself. Walters wanted to do this anyway—Phoenix Air was the only company in the world equipped to transport extremely infectious patients. BP, ExxonMobil, and the Chinese government, all of which had extensive infrastructure in Africa, were circling in an effort to nail them down for themselves.
In the end, Phoenix Air flew about 40 people who had, or who had been exposed to, Ebola from West Africa to treatment centers in the U.S. and Europe. Only two patients died, neither of them aboard the plane. The television stations, having been allowed to poke around inside the ABCS, dropped several degrees of melodrama. Brantly, who was the first human to receive a dose of Ebola-fighting antibodies known as ZMapp, recovered. Nancy Writebol, who was the second human to receive the antibodies, recovered as well. With a few hitches, including one time Dent was recognized by a barista in a chain coffee shop, who shouted “You’re the Ebola guy!” in horror and backed away, the hysteria gradually ebbed.
And then, mercifully, the outbreak in West Africa ended. The leftover ABCS units were moved back into a storeroom. Actual rolls of hay established themselves at the far edge of the lawn abutting the Cartersville office. Now that they had passed through the eye of the needle, Phoenix Air’s medical staff were given other delicate work for the U.S. Department of State, such as evacuating dignitaries and bringing home the imprisoned and allegedly tortured American student Otto Warmbier from North Korea. But you could tell they missed the drama of the Ebola years. Sometimes, the doctors had cried when the Phoenix Air folks, with the big American flag patches on the shoulders of their flight gear, disembarked from the plane to bring them home. They had been the angels who came out of the sky to save the saviors.
Who wouldn’t miss that?
December 26, 2018
Democratic Republic of the Congo
The doctors were winning: There were new tools for fighting the Ebola outbreak in the Congo that hadn’t existed four years earlier. In particular, an experimental vaccine that had been developed at Emory and tested on several Phoenix Air doctors was proving effective at combating the disease in Africa. Soon after his exposure, Dr. LaRochelle received the latest treatment.
Normally, LaRochelle would have completed his isolation in-country, either in Nyankunde or at a hospital in Beni, a town about 100 miles south, near Virunga National Park, which had all the latest experimental medicines. But the Congo’s eastern provinces are notoriously unstable, beset by warlords, loosely formed terrorist organizations, and genocidaires even in times of relative peace. Beni in particular had been targeted in bombings, motivated by mistrust of foreign doctors, that had driven Doctors Without Borders back to Goma, a larger town even farther south. Now, the government had declared that the town of Beni would not be allowed to vote in the upcoming presidential election. LaRochelle’s superiors feared the hospital wouldn’t be a safe place for him to spend three weeks.
Since 2014, Phoenix Air had expanded. They now had airplanes stationed in Los Angeles; San Diego; Norfolk, Virginia; Stuttgart; Nairobi; and Malta. After many interrupted Christmas vacations among State Department, NGO, and CDC higher-ups, it was decided that the Nairobi plane would come for LaRochelle. It was a Gulfstream III, which—regardless of violence—was of a size that could not land on any of the runways north of Goma. But that was fine. LaRochelle’s superiors told him he’d leave for Goma the next day.
The next morning, LaRochelle made his way south. First, he rode east to a town called Bunia in an NGO Land Cruiser whose driver he tried not to touch. Then he boarded a United Nations Humanitarian Air Service plane to Beni that was mostly empty. The general medical consensus on Ebola is that you’re not contagious until you show symptoms, but LaRochelle still preferred empty planes and cars where he could stay as far from others as possible. When his U.N. flight connected in Beni, however, aid workers were evacuating en masse ahead of the December 30 election (and after an attack on the Ebola isolation center, which had occurred that morning). The flight from Beni to Goma was full. “It was pretty uncomfortable being four inches from another person, knowing that that person would really not want to be next to me,” LaRochelle says.
Phoenix Air arrived around 4 p.m. local time. “They had [LaRochelle] in a safe house, that’s what they called it; it’s right out of a James Bond novel,” Dent says. The medical officers took LaRochelle’s temperature and decided he was well enough to ride in the plane’s seats until he felt ill. To LaRochelle, the whole trip felt like a weird formality: He’d been at risk, sure, but he never fully believed he’d catch Ebola. He spent most of the flight talking to the Phoenix Air staff about the towns that lie between Atlanta and his hometown of Chattanooga, Tennessee. If he’d developed symptoms, everything would have changed. He’d have moved back into the patient compartment. The crew would have notified Homeland Security and the State Department. The plane would have disappeared off radar, like a military flight.
When Phoenix Air dropped LaRochelle off at the isolation unit at the University of Nebraska, he was still healthy. He remained in the unit, which had a stationary bike and a treadmill and was surprisingly comfortable, until the 21-day stopwatch ran out. God or the vaccine or something even bigger intervened. He never got sick. A month and a half later he and his family were back in Nyankunde, taking turns at the hospital so their children wouldn’t be left alone if something happened again.
As for the woman who had come through with Ebola: It was almost miraculous, LaRochelle said. Although she died, she hadn’t infected anyone.
The Current Fight
“This is black ops, Ebola World, whatever you wanna call it,” Dent says, indicating a trio of warehouses, bare and tan, on the grounds of the Cartersville airport. Weeds poke out of an asphalt runway. There are no signs. Inside one of the warehouses sits a mock-up of the ABCS, right in the middle of the floor. This hangar is where the system would undergo a 22-hour post-use “decon,” short for decontamination, after use. Among other procedures, it would be bombarded with a 200-degree Fahrenheit, 35 percent hydrogen-peroxide solution, then collapsed, put in a special truck, and driven to a federal incinerator in Central Florida.
While the fight against the current Ebola outbreak in the Congo has been hampered by violence, international health organizations hope that experimental vaccines will prevent it from spreading as widely as the last epidemic. But they’re ready for the situation to deteriorate anyway. Governments are not fond of being unprepared for the same thing twice. In 2014, Paul Allen, of Microsoft fame, decided he wanted to put some of his fortune to use combating Ebola. He asked the Department of State what he could do to help, which is how he, together with Phoenix Air and a research company called MRI Global, came to build the Containerized Biocontainment System (CBCS).
If the ABCS is a rubber raincoat, the CBCS is a submarine, down to 400-pound airtight doors that separate the clean, gray, and biohazard sections. The size of a semi-truck trailer, it has its own power and medical oxygen, and can be loaded onto a Boeing B-747/400 and shipped out of Atlanta’s Hartsfield-Jackson International Airport within 24 hours. The CBCS solves a major problem Phoenix Air faced during the 2014 epidemic, which was that they could only pick up one patient at a time, every three days, potentially dooming anyone left behind to wait for a later flight. The CBCS can transport four extremely sick, extremely contagious people, along with six medical staff, simultaneously.
Here’s how the CBCS would work: Let’s say a bat with SARS bit a gorilla with Ebola and then the gorilla rolled in a patch of that ineradicable Candida auris fungus that’s currently infiltrating U.S. hospitals. Twenty doctors somewhere far away from medical infrastructure have come down with the resulting (medically impossible) super-plague. They will die if they aren’t airlifted out at once. Using a combination of Phoenix Air’s multiple Gulfstream aircraft and the CBCS units, the U.S. government could transport all 20 of the doctors to isolation units in Atlanta; Omaha, Nebraska; Bethesda, Maryland; and New York City—about 10 two-person treatment centers across the country, plus others in Europe. Other doctors, who were skittish about traveling to the epicenter to help, would see the effort to extract their contemporaries and be reassured. Presumably, the international medical system would hold.
If they ever need the CBCS, the U.S. Department of State will make phone call to Phoenix Air and request it. A local trucking company will come in, hitch up the custom trailer that sits under the unit, and drive it to Hartsfield-Jackson, where it will be loaded on a Kalitta Air 747 cargo jet. Mike Flueckiger and Vance Ferebee and the rest of the medical cowboys will go again to save the saviors. And the media will return to Cartersville, wondering what in the heck these local boys have gotten up to this time.
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