DALLAS—On the night of Sept. 25, a Liberian immigrant walked into the emergency room at a modern metropolitan hospital here, whose polished terrazzo floors and sleek tropical-fish tank were a world removed from the rundown clinics of his home country.
Barely a week before, Thomas Eric Duncan had excitedly arrived in Texas from Liberia’s Ebola-ravaged capital of Monrovia, with plans to reunite with his fiancée, Louise Troh, and their college-age son, Karsiah. Now his abdomen was hurting, and so was his head. He felt feverish, he told relatives.
So Ms. Troh took him to the ER at Texas Health Presbyterian Hospital Dallas, and asked for assistance. Eventually, a nurse asked Mr. Duncan what ailed him. When questioned if he had been around anyone who was ill, Mr. Duncan replied that he hadn’t, according to the hospital.
Medical staff requested Mr. Duncan provide proof of health insurance, a Social Security number and a driver’s license, and Ms. Troh responded in her thickly accented English that he had none of those things, that he was from Africa, according to a relative who spoke with her afterward. He was sent home that evening with a prescription for $40 in antibiotics, she said.
Thirteen days later, Mr. Duncan was dead, the first person diagnosed with Ebola in the U.S., and the first known casualty from the disease in this country, a case that has triggered tough questions about whether America is fully prepared for the potential spread of a West African outbreak that has killed more than 4,000 people, according to the World Health Organization.
A Wall Street Journal examination of the events leading to Mr. Duncan’s death—including interviews with friends and relatives of Mr. Duncan who spoke to him and Ms. Troh in his final days, and accounts from the hospital that eventually admitted and treated him—point to two major lessons from Mr. Duncan’s case.
It demonstrates that not all U.S. hospitals were ready to screen for Ebola, despite repeated warnings by the Centers for Disease Control and Prevention that they needed to be on guard for sick people from Africa, and that early detection was crucial. It also shows that not everyone potentially carrying Ebola will inform health-care workers that they were exposed to the disease in Africa, and that some may not even know it themselves.
Weeks before the death of Mr. Duncan, Ms. Troh’s household was filled with jubilation. Ms. Troh, 54 years old, and Mr. Duncan, 42, first met and fell in love some two decades earlier in a refugee camp in the Ivory Coast, driven there by a civil war in Liberia.
Although the two had been apart since Ms. Troh immigrated to the U.S. around 2000, they had stayed in touch. Ms. Troh gushed to friends and family that the father of Karsiah, a college student in San Angelo, Texas, was finally coming to America. The couple planned to wed, according to the pastor for Ms. Troh, who herself has declined to discuss the situation.
Mr. Duncan left his tin-roof home in Monrovia on Sept. 19, hoisting his rolling suitcase above the mud, recalled his next-door neighbor in Liberia. Beaming at the prospect of seeing Ms. Troh and his son, he said goodbye to neighbors who packed the concrete homes around his yard. He arrived in Dallas one day later, on Sept. 20 and happily phoned his half-brother, Wilfred Smallwood, who earlier emigrated to the U.S. and lives in Phoenix. “I said, ‘I’m going to come visit you, man.’ And he said, ‘I’m going to come visit you too,’ ” Mr. Smallwood said.
Ms. Troh’s friends and family were soon streaming into her apartment to meet the man she had often spoken of. Joe Joe Jallah, Ms. Troh’s ex-husband, said Mr. Duncan relayed how Ebola had ravaged Liberia, and recounted the rigorous health checkpoints he passed through to leave the country for the U.S. At no point did Mr. Duncan ever say he had been exposed to the disease, Mr. Jallah said, despite subsequent reports from his neighbors in Monrovia that he had driven a sick woman there to a hospital who later died of Ebola.
Mr. Duncan’s mood was upbeat, but Ms. Troh started to notice that he was unwell, her friends and relatives said. He seemed tired, and began complaining that his stomach and head hurt. Ms. Troh took him to Texas Presbyterian, a nearby hospital accustomed to treating the African and Asian immigrants who had settled in her working-class Dallas neighborhood.
Months before, Dallas County health officials started cautioning hospital officials about the need to be ready for an Ebola case, and Presbyterian had started preparing. The virus was tearing through West Africa, and CDC officials were warning U.S. emergency rooms to be vigilant for potential Ebola cases and issuing guidance on how to handle them. But for reasons that remain unclear, something went wrong when Mr. Duncan arrived at the ER.
Princess Duo, a niece of Ms. Troh who lives in Dallas and spoke with her following the ER visit, said Ms. Troh recounted being specific in the information she gave nurses that night. “They asked him for ID, and whether he had insurance. And she told them he did not because he had just come from Liberia,” Ms. Duo said.
Hospital officials initially said that due to an electronic-records glitch, information that nurses collected about Mr. Duncan’s travel history was not seen by doctors. But the hospital reversed its position 24 hours after making that statement, saying that Mr. Duncan’s intake information was available to the entire ER staff that night. Hospital officials haven’t commented further on why Mr. Duncan wasn’t initially admitted despite the fact he came from an Ebola-torn country.
Dr. Joseph McCormick, who worked to contain Ebola epidemics in Congo and Sudan, said that Mr. Duncan’s recent arrival from Ebola-torn Liberia should have raised red flags in the emergency room, even if his symptoms weren’t yet severe.
“Taking a travel history is medicine 101,” said Dr. McCormick, now regional dean at the University of Texas School of Public Health campus in Brownsville. Not taking that into account, he added, is “inexcusable.”
Mr. Duncan’s relatives, as well as some black leaders around Dallas, have also questioned whether he was given short shrift because he was an uninsured immigrant.
“He did not have insurance and was of full African background, so he was turned away and didn’t get the treatment he should have gotten,” said Josephus Weeks, Mr. Duncan’s nephew.
Texas Presbyterian strongly disputed those claims, saying, “Our care team provided Mr. Duncan with the same high level of attention and care that would be given any patient, regardless of nationality or ability to pay.”
The day after Mr. Duncan was sent home from the ER, he told his brother that he hadn’t felt great and had gone to the hospital to get some medicine. Mr. Smallwood chalked it up to jet lag.
“I said ‘welcome to America,’ and we both laughed,” Mr. Smallwood said.
But Mr. Duncan didn’t get better. His temperature rose, he lost his appetite and developed diarrhea, according to relatives and friends who visited Ms. Troh’s apartment. On Sept. 28, three days after Mr. Duncan initially sought help at the ER, Ms. Troh’s daughter, Youngor Jallah, a nurse’s aide, dialed 911 after measuring his temperature at 104 degrees.
When she told ambulance responders that Mr. Duncan was from Liberia, they donned masks. The emergency technicians called Texas Presbyterian, warning that they were coming with “a very suspect case,” Dr. Gary Weinstein, the hospital’s chief of critical-care medicine, and one of those who treated Mr. Duncan, later testified before Texas legislators.
This time, he was admitted. Two days later, blood tests confirmed that he had Ebola, setting off a scare in Dallas and forcing public-health officials to hunt down everyone he had been in contact with to contain a potential outbreak. So far, none of the people being monitored have contracted the disease.
At Texas Presbyterian, an entire 24-bed intensive-care unit was cleared so that other patients and medical staff could be safe. The day that tests confirmed an Ebola diagnosis, Ms. Troh had an emotional conversation with Mr. Duncan, who was still able to speak by phone. “He told her that if he had known he had Ebola, he would have rather died in Liberia than come to the United States and expose Louise and the family,” said Ms. Duo, her niece.
More than 50 doctors and nurses scrambled to lay out a course of treatment, consulting daily with the CDC and an Emory University team who cared for the first Ebola patients brought to the U.S. But with no specific treatment for Ebola, all doctors had to rely on were supportive measures, such as keeping him hydrated and supplying oxygen, and largely untested experimental therapies.
Making matters worse, Mr. Duncan’s physicians had had no access to ZMapp, an experimental drug used in treating other Ebola patients, because supplies had run out. Dr. Brett Giroir, who heads the Texas A&M Health Science Center and was appointed by Gov. Rick Perry to oversee a state task force, said he called officials to make sure there wasn’t a dose somewhere. There was none.
An alternative was brincidofovir, a drug whose effectiveness has been little studied, said Dr. Giroir. “These are experimental, unproven therapies with very limited data in humans,” he said, adding that trying them is “a very difficult decision.”
Mr. Duncan received brincidofovir on Saturday, “as soon as his physicians determined that his condition warranted it, and as soon as it could be obtained,” the hospital said, adding that it believes he was the first Ebola patient ever treated with it.
Mr. Duncan’s family grew frustrated. Ms. Troh told family she couldn’t get information about how he was doing because they weren’t married. Karsiah tried to visit his father but was forced to remain in a waiting area, said Saymendy Lloyd, who is serving as a spokeswoman for Ms. Troh.
Still, family felt optimistic earlier this week, when Mr. Duncan had shown signs of improvement, and even started to eat a little. “I told Louise, ‘I’m sure he will live. This is the world’s best health-care system,’ ” Ms. Duo said.
But at 7:51 a.m. on Wednesday morning, Mr. Duncan’s heart stopped beating. There was nothing more to do. He had instructed doctors that he didn’t want them to attempt to revive him.
Ms. Troh’s pastor and Dallas County Judge Clay Jenkins came to her door. They told a grief-stricken Ms. Troh that her fiancée was gone.
“It feels unfair to her,” Ms. Duo said, adding, “He didn’t get the treatment like everybody else.”