‘I thought I’d be next’: Working in the ‘red zone’ of the world’s deadliest disease
When the throbbing headache set in, Dr Menelas Nkeshimana was convinced his time was up.
The 42-year-old doctor had been in Rwanda’s “red zone” for weeks, treating patients critically ill with one of the world’s most dangerous pathogens – an Ebola-like hemorrhagic fever called Marburg. The headache, he thought, was an early sign that he was the latest victim.
“What stuck in my mind was that mortality can go as high as 90 per cent,” he says, speaking over a video call from the response team’s quarantined quarters in Kigali. “I knew that this was probably the most dangerous situation I was going to be involved in… and I cannot hide it from you, I thought I would be next.”
Almost 80 per cent of Rwanda’s 66 Marburg patients have been doctors and nurses, and Dr Nkeshimana’s brain jumped to a worst case scenario. So when he had a headache and fatigue, both early symptoms of the virus, the outcome seemed inevitable.
“You think you are going to be taken out of the doctor’s residence, and put on the bed where your colleague died days ago,” he says. “You think you’ll be receiving the prescription you’ve been given to others, and you know it might not work. You think you’re going to die of something you can see, because you’re going to bleed – and that you’ll feel the same fear you’ve seen in your patients.”
Yet now, after six weeks on the frontlines of Rwanda’s first Marburg outbreak, Dr Nkeshimana is increasingly optimistic that he’s escaped that fate.
Over the weekend, the specialist treatment centre he set up discharged its final patient, kick-starting a 42 day countdown. If there are no new cases by December 20, the epidemic will be declared over, after 66 infections and 15 deaths – a remarkably low case fatality rate, given the size of the outbreak.
“At the start, I told myself either I use the knowledge I have to go and serve, or I stay home and the disease finds me anyway,” says Dr Nkeshimana, whose parents named him Menelas after the Spartan King of Greek myth. “I thought I was just there to be a shield for others, I never thought that I would get out without being infected.”
Marburg is a terrifying, highly contagious disease from the same family of viruses as Ebola. First detected in 1967, it is named after the German cities where one of the known first outbreaks emerged, in scientists who handled African green monkeys imported from Uganda.
In all, 19 outbreaks have been reported, varying widely in size. In a dozen instances, fewer than 10 people were infected. But in the worst outbreaks – when 347 people were infected and 329 killed in Angola in 2005, and in Democratic Republic of Congo in the late 1990s, where there were 154 cases and 128 deaths – the fatality rates were higher than 80 per cent.
But there are mounting concerns that Marburg, which lurks inside fruit bats, is spilling over from wildlife to people more and more frequently. The most recent outbreak in Rwanda is the fifth epidemic since 2021.
The first case came in September, when a person who tested positive for malaria was hospitalised with complications. In the early stages the two diseases have similar symptoms, including a fever and body aches, and it was not until other people began falling ill that clinicians realised the individual also had Marburg – likely contracted from fruit bats in a mining cave.
But by that point it was too late. The virus – which spreads through direct contact with the bodily fluids of infected people – had already spread among the patient’s family. Rwanda’s healthcare workers were also hit hard, and testing found two of the country’s leading hospitals in Kigali were dealing with growing outbreaks.
It was around this time, in late September, that Dr Nkeshimana checked his phone during a meeting and saw 10 missed calls. Now head of the department of health workforce development at the Rwandan Ministry of Health, he previously led the emergency department at the University Hospital of Kigali, and was designated a first responder in an infectious disease outbreak.
“When I got on the line I already knew it must be serious. I said, what kind of disease are you talking about? Is it Ebola? [My colleague said] ‘no, it’s number two on the list’,” recounts Dr Nkeshimana. “The call was in the morning, and he said to be ready by 1pm, because that’s when I’ll give you patient number one.”
For the next few hours, Dr Nkeshimana was rapidly phoning through the list of trained 24-hour responders, who had taken part in pandemic simulations in preparation for this eventuality.
“Actually, as expected, some of them were very afraid and were not willing to join,” he says. But enough were; by 1pm, they had assembled at the new treatment centre, while their colleagues “hijacked” a nearby hotel that became their isolated base, to prevent them taking any infection home.
“It was very, very, very, very scary,” says Dr Nkeshimana. “When we reached the treatment facility to go to the patient area… there was another obstacle to pass: who was going inside first? You could see people trembling. They have the knowledge, the experience, they are the best in this area. But they are already trembling, we were all scared.”
The first week was the worst. “It was very, very, very deadly because the people had an advanced stage of disease, and the team were getting used to the working environment, getting beyond their fears,” Dr Nkeshimana says, adding that the majority of the 15 people who lost their lives died that week.
‘What if I did something wrong?’
Treating Marburg is no mean feat, and not just because there are no specifically approved treatments or vaccines. Patients in the clinical, white health facility were suffering from severe vomiting, diarrhoea, and fevers as high as 42 degrees. As their conditions deteriorated, they bled heavily.
Meanwhile the doctors and nurses responding – who nearly all already knew at least one patient by name – were donned head to toe in critical, but hot and cumbersome, personal protective equipment (PPE).
“We had massive sweats. You would cope with probably two hours in PPE, then we’d carefully come out of the red zone to go to the green zone, drink water, and let someone else take over,” says Dr Nkeshimana. “Every time you came out of the red zone you just kept thinking, what if I did something wrong, for example in the way you removed or put on your clothes, and I got infected?”
The team, who were closely monitored with health and temperature checks, had to follow rigorous infection control regulations on everything from the order they removed their PPE, to where they kept their paperwork. Nor were they able to go home, instead staying at a hotel requisitioned for an “isolated bubble”.
But even with all of the precautions, infections happened – towards the end of the outbreak, one of Dr Nkeshimana’s colleagues tested positive. He’d had dinner with her the night before.
“That was very unfortunate and very scary as well, because among ourselves, the treatment team, we don’t have restrictions. We can eat in the same hall, we can discuss, we can laugh and have tea together in this residence that we stay in,” he says. But fortunately, the woman made a full recovery.
“She started as a responder, she became a patient, but now she is a survivor. So this can happen to anyone.”
Overall, Rwanda’s stress-tested preparedness plans, contact tracing networks, and health resources meant the case fatality rate was far lower than feared, at 23 per cent, compared to 83 per cent in the DRC and 88 per cent in Angola.
The response also tested more than 6,000 people, helping to identify patients rapidly, and demonstrated that lives can be saved with strong supportive care – in what the World Health Organization called a first for Africa, two intubated patients went on to survive.
Meanwhile, strong existing partnerships allowed the country to receive experimental antivirals and vaccines at record-breaking speed.
“I can’t imagine another scenario in which a country went from identifying this outbreak to just over a week later having investigational [experimental] vaccines in country already being provided to frontline health-care workers,” Dr Craig Spencer, an emergency physician and professor at Brown University School of Public Health, told NPR, adding the doses were rolled out the same day that they arrived.
“I rarely, rarely use the word unprecedented in global health response,” Dr Spencer says. But in this instance, it was valid.
Dr Nkeshimana’s own contact book was partly behind the speed – he had met representatives from the firm Mapp Biopharmaceutical several times, and emailed them asking for help. Within a week, their antivirals had landed at Kigali airport.
“The antivirals played a role in many people surviving, it was a game changer,” he says. “We started with a lot of fear, you would see us exhausted and hopeless. But when we started seeing people recovering, like dying and resurrecting… you then get the hope you can survive. That keeps you going.”
Dr Nkeshimana adds that there are two main lessons he’d like others to take from Rwanda’s experience: the importance of preparation, and the knowledge that Marburg is no longer a death sentence.
“In the past, Marburg patients were sometimes just isolated, and left to die. But now, we have shown we really can treat them… So I think there is a lot we can share with our neighbours.”
But for now, Dr Nkeshimana is counting down the days until he leaves the isolated hotel he’s called home for six difficult weeks. If all goes to plan, he’ll be reunited with his family by Friday, eight days after he last went inside the treatment centre.
He’s looking forward to seeing his nephews, aged eight, nine and 16 – who he usually takes to practise archery each weekend. But he’s also excited to do “something normal”.
“I’ll be able to have coffee downtown, or hang out with friends, greet people, maybe hug people without restrictions,” he said. “I think I will organise one or two evenings with friends in town, to laugh, and listen to music, and to do something normal. Just something normal.”
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