The pickup truck was so overloaded with medical equipment that the chassis sagged almost to the ground. Dr. Austin Demby had just finished loading up the Toyota Hilux with as many microscopes, IV bags, computers, and lab and chemistry equipment he could fit in the extended bed. And as fast as possible, he sped away from the hospital in Segbwema, Sierra Leone.
Literally under gunfire, Demby and his colleagues were fleeing the Revolutionary United Front, a violent and destructive rebel army. It was 1991, and a brutal civil war had just erupted, putting the staff at Nixon Memorial Methodist Hospital at extreme risk. So, they were evacuating.
Darting along the muddy roads, they drove into a deep pool of rainwater. Suddenly, the truck stalled. They opened the hood but couldn’t figure out what was wrong. The battery seemed fine.
“I just went back in and prayed and turned it and it quickly fired up and I just put my foot on the pedal and zoomed out of there,” Demby told Ars. They drove about 40 kilometers to Kenema, Sierra Leone’s second largest city, but they weren’t there for long. “We couldn't stay because Kenema was slowly being surrounded, and so I moved my staff and the US-government supported program out of the country.”
Since 1976, the Centers for Disease Control and Prevention had been running a Lassa fever research program in Sierra Leone, which Demby began directing in 1987. Lassa is a viral hemorrhagic fever closely related to Ebola, characterized by rare, but severe, vascular leakage—a clinical way of saying the body is so overwhelmed with fluids that it begins to leak blood from every orifice (yes, mouth, eyes, anus, vagina, etc.). It’s difficult to detect, deadly, highly contagious, and has no vaccine.
Lassa, which is endemic to West Africa, is somewhat of an ignored, forgotten disease. While news of Ebola outbreaks regularly splash headlines, Lassa is fairly unknown, despite annually infecting around 300,000 people and killing 5,000 per year. Little was known about the virus, named for the Nigerian village where it originated in 1969. The CDC had accomplished much in the prior 15 years, such as learning how to better detect and manage infections, but Demby and his team had to flee an even more deadly virus: war.
“It's not running away,” Demby said. “We'd done quite a bit. It was just not safe to be there at that point, so turning over the skills, assets, and all of the equipment and supplies that we had to the host government was the right thing to do.”
Yet, amidst the chaos and violence and disease, one man stayed behind. His name was Dr. Aniru Sahib Sahib Conteh, a modest physician from Sierra Leone. With few resources and a skeleton crew, Conteh would spend the next 11 years treating Lassa patients in the middle of one of his country’s—heck, history’s—most horrific war zones.
Decades later, it’s clear Conteh’s work helped revolutionize the way Lassa is diagnosed and treated, and his persistence amidst civil unrest and human rights violations provided a framework for others battling hemorrhagic fevers and emerging diseases in some of the world’s most in-need environments. By one estimate, Conteh’s work reduced Lassa mortality by 20 percent. He saved countless lives. He even housed refugees in his own home.
However, not long after the war finally ended, an accidental needle prick led to Conteh’s own Lassa infection. He eventually succumbed to the disease that he had dedicated his life to fighting. But while Conteh and the virus that killed him are widely unknown, his example continues to inspire others and shape the approach to fighting devastating viral outbreaks in Africa and beyond.
Danger within the dangers of war
The Sierra Leone Civil War broke out in March 1991, as the Revolutionary United Front attempted to overthrow President Joseph Momoh, a former major-general who won a 1985 election in which he was the lone candidate. Momoh inherited a profoundly corrupt and nearly bankrupt government, leading him to slash health and education budgets. An uprising soon followed.
Led by ex-army corporal Foday Sankoh, the RUF were notoriously vicious, spreading sexual violence, torture, mutilation, and indiscriminate death throughout the small West African region. They were aided by Charles Taylor, a guerrilla leader and war criminal instrumental in another civil war in nearby Liberia, one that started two years earlier.
In turn, Taylor received cash and guns from numerous outside groups, including Libyan dictator Muammar Gaddafi; Blaise Compaoré, president of Burkina Faso; and Viktor "Merchant of Death" Bout, a notorious Russian arms dealer. Blood diamonds abundantly mined throughout the lush landscape also played a key role in financing the brutal conflict. (Yes, the Leonardo DiCaprio thriller Blood Diamond takes place during this time.)
The RUF recruited child soldiers, amputated limbs, and massacred civilians without restraint. Some rebels would bet on the sex of unborn babies, then eviscerate the pregnant mothers with machetes to determine the winner. They looted and destroyed any government or medical building they came across, including the Methodist hospital Demby called home at the time. When the dust settled in 2002, the war had killed around 70,000 and displaced 2.6 million people, roughly half the population, according to a United Nations report.
After fleeing the hospital and with nowhere to go, Dr. Conteh spent months wandering the countryside, hungry and fearful. Eventually, he wound up in Kenema and began treating war victims at a small clinic. He often considered escaping, perhaps fleeing to Nigeria or elsewhere. He was a skilled doctor who could easily find work somewhere, anywhere else.
“But how could I leave?” Conteh told one of his students, Ross Donaldson, as outlined in Donaldson's book, The Lassa Ward. “My people, they had no one to help them.”
After Conteh diagnosed a patient with Lassa, paranoid medical staff at the makeshift clinic began referring all Lassa patients to the doctor. He was the only one willing to treat the disease, which he had become intimately familiar with after joining the CDC’s Lassa team in 1979. Conteh trained a few nurses with donated supplies and borrowed money, and, in 1991, he soon opened the world’s only Lassa fever isolation ward.
The grounds at Kenema Government Hospital were (and largely remain) a scattering of one-story buildings in a gravel courtyard. The Lassa ward was a small outlying concrete compound encircled by a tall barbed wire fence pegged with warning signs. Generator powered, the building had few rooms and as few windows. The smell of bleach and blood was omnipresent.
Medical staff working elsewhere avoided the ward, its patients, and its doctors as if it were a leper colony. The lab was so primitive it didn’t even have the capacity to actually confirm Lassa cases—Conteh was forced to rely on his intuition, but few, if anyone, knew the disease better than he.
It was a far cry from the fortified biosafety level 4 labs that typically analyze viruses like Lassa. Instead of positive pressure protective suits, the bulbous astronaut-like outfits standard for handling deadly substances, staff at the Lassa ward wore two pairs of gloves, surgical gowns, eye goggles, and a face mask. The nurses’ hand washing station was a table and two buckets. Yet, it was all that could be done, and under Conteh’s administration, the earnest efforts saved the lives of untold thousands.
By 1996, a big portion of funding for the ward came from Medical Emergency Relief International, or Merlin, a British non-profit health charity specializing in conflict zones. Nearly a decade later, Conteh would become the first recipient of the organization’s Spirit of Merlin Award to honor people who exemplified its values. Nicholas Mellor, one of the organization’s co-founders, doesn’t specifically remember how the NGO learned of Conteh’s operation. But in these kinds of situations, he says, there aren’t many medical healthcare workers left to begin with.
“At that particular time, there was only one anesthetist in the whole of the country,” Mellor said in a call with Ars, describing West Africa as “the world's Achilles heel” for these emerging infections. “You are very much the last person standing in these kinds of places.”
The life of Lassa
Acting as a scented getaway route, all rat species leave a trail of urine as they walk—something to consider during your next family viewing of Ratatouille. But there is something deadly lurking in the piss of the natal multimammate mouse—an arenavirus called Lassa.
Mastomys natalensis, so named for the many nipples dotting its belly, is estimated to be the most common rodent in Africa. In other parts of the continent, the small, brownish rat carries other arenaviruses, such as Mopeia and Luna virus. As Sierra Leone’s civil war raged on, abandoned homes became infested with more rats, leading to more Lassa infections.
War-torn regions are also scarce for food, making rat meat an important protein source for Sierra Leoneans. Lassa virus can be destroyed by boiling, but infection can easily occur while hunting and handling the rats, by eating food tainted with urine and feces, or even through skin absorption. Children sometimes kept the rats as pets or played with those found “drunk” with poison.
Healthcare workers in Sierra Leone once attempted to control the rodents by giving citizens cats. It backfired, however, when people instead ate the felines—a testament to the level of poverty citizens faced.
The CDC once called control of the rodents “impractical,” but in recent years health campaigns addressing Lassa have made progress, including wider use of traps and increased sanitation. But one of the most effective strategies overall has been simply learning how Lassa spreads and kills.
It begins with aches and a high fever, making it difficult to distinguish from typhoid or malaria—common infections in Africa. In about 80 percent of Lassa patients, it has no symptoms; for others, the disease is nothing short of horrific.
The virus incubates in its host for one to three weeks, in rare instances progressing to fluid retention in the face, convulsions, bloody vomiting and diarrhea, hemorrhaging, coma, and death. Even in mild cases, it can cause patients to go deaf.
If Lassa is detected early, an antiviral drug called ribavirin can improve outcomes, but it requires high doses, which can be expensive. Ribavirin can also cause side effects like anemia, flu-like symptoms, and heart problems, plus it’s not yet clear how exactly it helps. Otherwise, Lassa has no reliable treatment or vaccine. Though some are being developed, not much attention has been given to drug development for the virus, given that Lassa fever cases are incredibly uncommon in the West. Only on rare occasions, like when a New Jersey man returned from Liberia and died from Lassa in 2015, will Western media give the disease attention.
In mid-'90s Sierra Leone, however, Conteh witnessed whole households wiped out within a week. Frightened families would shun the infected and burn down their homes to prevent the spread. If enough perished, entire villages would be shut down.
Lassa very much still looms today. There was a severe 2018 Lassa outbreak in Nigeria, the country’s largest ever. Last year, there were 633 confirmed cases and at least 171 deaths, plus another outbreak with 60 confirmed cases and 16 deaths so far in 2019, but Western coverage has been sparse. An Ebola outbreak in Congo, however, has received generous attention despite a similar 640 confirmed cases and 373 deaths to date
A humble doctor
Aniru Conteh was born August 6, 1942 to the chief in Jawi Folu, a small village in the Eastern Province of Sierra Leone. His mother died when he was 16, and he ran away from school to care for his family. When he returned, he studied biology and chemistry at Fourah Bay Colleges in Freetown, earned a bachelor’s in science through Durham University, and taught before entering medical school at University of Ibadan in Nigeria in 1968.
Twelve years later, Conteh became the first African medical superintendent at Nixon Methodist Hospital in Segbwema, where he worked until the war arose. During the years spent in Segbwema before war pushed him to the Kenema Lassa ward, Conteh met his wife Sarah, and they ran a small café that was popular with locals. Together, they had six children: Isata, Kenneth, Eugene, Mohammed, Alfred, and Anita. A few now work in medicine like their father.
“He was a very loving and caring father,” Kenneth Conteh, 49, told Ars in a call. “He was always there for his children, made sure we had every support we needed, and guided us on our life's journey to where we are today.”
Like his family, Conteh was deeply dedicated to his patients. He spent most of his time in the hospitals, sometimes conducting surgeries deep into the night. He often didn’t charge his patients, Kenneth said, putting their lives before money. His family often took in refugees, which inspired others to help those fleeing violence and persecution.
“To move all your whole family to a location where [you’re] dependent on generator for electrical power for eight hours a day, leaving all those amenities behind to come and serve your people was indeed laudable,” Demby said. “He put his people first, he put their livelihood and their health first, and it's a rare attribute in a very self-centered and self-focused world.”
Conteh’s impact extended well beyond his immediate patients and community, too. Although he was sometimes not explicitly credited, throughout the ‘90s the doctor had a hand in much of the published research on Lassa (if curious, the literature still remains relatively small compared to, say, HIV or Ebola). When CDC researchers needed blood samples containing the virus, for example, they knew who was best to contact. And during his time working in Sierra Leone medical facilities, it’s unlikely anyone saw as many cases of Lassa as Conteh.
Dr. Daniel Bausch, a former Lassa researcher for CDC and professor at Tulane University Health Sciences Center, has described Conteh as “a model of the dedicated healthcare worker” and “the elder statesman of Lassa—really the sort of person that you would go to for knowledge on it.”
In 2000, Bausch, Demby, Conteh, and eight other researchers published a paper in the Journal of Clinical Microbiology describing a more sensitive test for detecting Lassa. Blood samples were provided by four hospitals in Guinea and Kenema Government Hospital between 1996 and 1998. The war in Sierra Leone was causing frequent power outages, making it difficult for samples to be stored under sufficient chilled temperatures, but the team was ultimately able to provide more than 80.
“[Conteh] was the guy in the trenches, on the front end of patient care, collecting the things that were needed to do this research,” Bausch told Ars. “It would be not true to say that he was the primary force for that, but he was an important part of it.”
While still a student, another medical professional named Dr. Ross Donaldson heard of Conteh during a lecture at London School of Hygiene and Tropical Medicine. He was so drawn to the Lassa doctor’s work that in summer 2003 he traveled to study under Conteh while writing his master’s public health thesis: a practical guide for the treatment and control of Lassa fever.
Young and somewhat naïve, Donaldson soon realized the gravity of his situation. Little more than a week into his apprenticeship, he arrived at the ward to a scene of a young boy with Lassa who drowned after fluid overwhelmed his lungs. His body was like “a punctured water balloon,” leaking contaminated liquid from every orifice.
“It was kind of a slow creep, as I just slowly appreciated what I'd gotten myself into,” Donaldson told Ars. As Donaldson began his rounds, he realized that more than a fifth of those he saw would die within “the dark recesses” of the Lassa ward. He had dissected plenty of cadavers in med school and worked as an EMT, but he wasn’t prepared to treat such dramatic illness in such squalor.
By the end of this unique internship, Donaldson found himself with a profound appreciation for his mentor, who for so long had managed the ward singlehandedly. He credits the experience with being the first time he felt like a true doctor. Donaldson later applied what he’d learned in Conteh’s Lassa ward as the lead architect of numerous national emergency care plans in Iraq, Haiti, and other conflict zones. He is now director of the Emergency Medicine Global Health Program at the Harbor-UCLA Medical Center in Los Angeles.
“Doing stuff yourself is good, but teaching other people to do stuff potentially has a much greater impact,” Donaldson said. That’s why his humanitarian work has focused on “capacity building,” which he described as “trying to teach local physicians, many of whom are the younger version of Dr. Conteh, essentially.”
Years after his experience with Dr. Conteh, Donaldson wrote a memoir that he says helped him grieve with Conteh’s passing. The book is dedicated to Conteh, his mentor and friend, and Donaldson subtitled it “One Man’s Fight Against One of the World’s Deadliest Diseases,” referring to Conteh.
“I was a mere visitor passing through,” Donaldson concluded. “They were the true heroes, those who stayed behind.”
The deadly paradox of peace
When a war breaks out, depending on the region, humanitarian aid immediately begins pouring in. Non-governmental organizations like Doctors Without Borders, as well as three-letter health agencies from across the globe, spring into action, airdropping crates of food, water, medicine, and other supplies. But once a conflict is over, it can be a different story.
“As soon as the peace sort of breaks out, it's switched on to a development basis,” Mellor said. “Funding cycles are longer and you end up going through this valley, quite literally a valley of death.”
On January 18, 2002, the United Nations Special Representative of the Secretary-General declared an end to the civil war in Sierra Leone. More than 72,000 rebels were disarmed, including 6,800 children.
Conteh’s salary soon dried up, so he began working double shifts at private clinics. His staff were tired and overworked. He was drawing blood from patients himself. This was a period, as Donaldson saw firsthand, where mistakes were easy to make.
The situation was complicated by the fact that Conteh was older than most and was slowing down physically, Bausch said. Donaldson described the beginnings of cataracts in his eyes and mentioned he’d tried to retire for several years but could never find a replacement. Even as any onlooker could see the job wearing on him, Conteh remained mild-mannered about his sacrifice.
“He wasn’t a guy who was arrogant or a braggart or anything like that,” Bausch said. “He just was a guy who really did his work and saw his calling as a physician to do this. He became an expert in it and really contributed a lot… Years of just toiling away in a war-torn area with a dangerous disease is certainly something worthy of respect.”
On March 17, 2004, Conteh was treating a pregnant patient, one of his volunteer nurses. She displayed signs of Lassa fever.
“When you are looking after a colleague who's now ill, it’s very difficult not to be more emotional and perhaps cross red lines that you would never normally do,” Mellor said. “And that's exactly what happened.”
Staff members were having enormous difficulty obtaining blood from the woman’s arm. So Conteh tried to puncture her femoral artery and accidentally pricked himself with a needle. The patient died the next day.
Less than a week later, Conteh developed a fever. He immediately took ribavirin but could not stop the profuse vomiting or diarrhea. The massive fluid loss led to hypovolemic shock, in which the heart cannot pump enough blood. Conteh had a heart attack and was revived, but he was bleeding and his kidneys were failing.
Less than a month later—on April 4, 2004—Aniru Conteh died, a patient in the ward he had managed for so long. It appears he had beaten the early stages of Lassa but succumbed to renal failure instead. He was 61.
Unlocking Lassa’s secrets
As Conteh continued to treat Lassa patients throughout his final post-war years, interest in the disease started to build elsewhere. In the US, following the September 11 attacks, when anthrax began finding its way through the postal system, the federal government looked into other things that could be adapted as biochemical weapons. Being an airborne contagion with little defense against it, Lassa virus topped the list.
To head up research, the feds tapped virologist Dr. Robert Garry from the Department of Microbiology and Immunology at Tulane Medical School in New Orleans, which is how he first heard of Conteh. Garry, who previously developed HIV diagnostics in the early days of AIDS, has published more than 100 papers related to retrovirology. Because of Hurricane Katrina, Garry never had the opportunity to meet Conteh in person. Yet, the Sierra Leonean doctor had a major impact on the virologist’s work, Garry said.
Following the push to defeat Lassa after Conteh’s death, the first major challenge Garry faced was, like with HIV, figuring out how to detect the virus in the early stages. Again, because Lassa is a febrile illness, it camouflages as malaria and a dozen other diseases in Africa, which makes it difficult to catch before it turns deadly or spreads.
“So we needed to make modern-type diagnostics, and that’s what we did,” Garry told Ars in a call. “We got an NIH [National Institutes of Health] grant for that, and that was actually a grant that we had brought Dr. Conteh on. Unfortunately, before the grant could be implemented, he had contracted Lassa fever and died from it.”
The diagnostic, called ReLASV rapid diagnostic test, is a dipstick inserted into a culture tube containing four drops of blood. It’s 90-percent sensitive to viral antigens and can show results in as little as five minutes.
Two other Lassa detection methods, including the test that Conteh helped develop in 2000, can take up to four hours for results. A combination of these three tests is recommended, but in the time it takes for results from the more sensitive ELISA test, patients can be put on ribavirin and isolated to prevent further spread of the disease.
The next challenge has been creating a drug treatment or therapeutic for Lassa, which Garry’s lab is presently working on. They developed a promising cocktail of cloned human antibodies, which blocks infection. But while the drug, called Arevirumab-3, has shown great results in guinea pigs and crab-eating macaques, human clinical trials are still far off.
“We've treated monkeys as late as eight days into the infection. The animals start dying like day nine or ten,” Garry told Ars in a call. “The monkeys have high levels of virus, fever, all the signs and symptoms—they’re pretty sick monkeys. And the drug so far has been able to bring them all back.”
The final stage in defeating Lassa is creating a vaccine. Garry’s lab is actually on the verge of developing a combination Ebola and Lassa vaccine, a two-for-one blast that would be especially useful in West Africa. Separately, research published in Nature Communications in October demonstrated a dual Lassa and rabies vaccine called LASSARAB that showed great protection from the viruses in rodent trials. The next step is to test the vaccine in nonhuman primates, before moving on to human clinical trials.
“I think we’re able to start through Dr. Conteh’s help,” Garry said. “It has led to some very important things, and, hopefully, we’ll be able to respond to Lassa fever a lot more effectively going forward.”
Is a Lassa-free future possible? Will thousands of annual infections someday drop to zero? This year marks the 50th anniversary for the discovery of the disease, and Nigeria just held its first international conference addressing the disease. It's absolutely possible; Lassa's days seem numbered.
Still, the journey forward is long. Garry’s team still needs to complete more animal experiments to see what the lowest effective dose of Arevirumab-3 is.
“Those experiments don't go quickly,” Garry said. “But we're on track.”
Back in Sierra Leone, the Lassa ward’s history does not end with Dr. Conteh. Instead, his death was described as a “tipping point” by a CDC scientist, leading to the establishment of the Mano River Union Lassa Fever Network in 2004, which continues to fight infectious disease across West Africa. The ward is still open today, and it’s in the process of moving to a bigger facility built in 2012.
The ward continues to outperform its means on a regular basis, providing almost herculean care in the face of some of medicine’s most difficult diseases. In 2014, during the largest Ebola outbreak in history, more than 11,000 people in West Africa were killed. The Lassa ward was converted to fight the more deadly, more infamous viral hemorrhagic fever.
Sheik Umar Khan, the young doctor who took over the ward following Conteh’s death, ultimately suffered the same fate as his hero, perishing from a viral hemorrhagic fever (Ebola) he had dedicated his life to fighting. Many other healthcare workers also perished in the 2014 outbreak. Garry estimates that out of his team of 40 workers, 11 were infected with Ebola and seven died.
Ultimately, the story of Conteh and the Lassa ward does not merely illustrate the history of one person or two but hundreds, if not thousands, of healthcare workers who silently perish on the front lines of the world’s most dangerous illnesses in some of the most abhorrent conditions on Earth. And although their actions may not always be visible, their dedication and sacrifice—sometimes including their own lives—lays the groundwork for future generations. They are not forgotten. And their impact saved lives then, now, and going forward.
Troy Farah is an independent journalist and photographer from Southern California. His reporting has appeared in Smithsonian, Discover Magazine, Undark, VICE and others, and he co-hosts the drug policy podcast Narcotica. He can be found on Twitter (@filth_filler) and at troyfarah.com.
