Tsion Firew had just finished running a first aid training when she glanced down at her phone — and then looked up confused.
The message she saw was about a colleague Firew had worked with a few days earlier in the emergency department at King Faisal Hospital in Kigali, Rwanda. "She's very young, full of energy, one of the smartest nurses I've ever worked with," recalls Firew, who is chair of emergency medicine at Africa Health Sciences University in Rwanda.
The message simply said: "Pray for her."
Firew rejiggered her schedule and made a trip to the intensive care unit. As Firew peeked around the screen that divided the patients, she saw the young energetic nurse and was taken aback. The woman was almost "lifeless." Eyes barely open. Not recognizing familiar faces.
"It was quite scary, because you had no idea what you were dealing with," Firew says.
Soon it became clear.
This was one of those moments where the job of a health care worker can quickly go from risky to deadly.
On September 27, 2024 Rwanda announced the country's first Marburg outbreak — a deadly virus that's a cousin to Ebola. For Firew, it was the beginning of a harrowing journey. She sent her 1- and 3-year-old children to another country. She faced pressure from her family to stop working as an emergency room doctor for her own safety. And she hallucinated from sheer exhaustion.
Now, a year later, the basics of the outbreak in Rwanda are known. It most likely started with a 27-year-old miner who caught the virus from a bat in a rural mining tunnel. It ended on December 20, 2024 and had garnered international renown as a model for a successful outbreak response.
Marburg is notorious for its high death rate, sometimes killing almost 9 out of every 10 patients. But the small country in east-central Africa achieved the lowest death rate ever recorded in an outbreak: 23%. Only 15 of the 66 Marburg patients died. Of all the Marburg patients in Rwanda, more than three-quarters were health care workers, many were Firew's friends and colleagues.
Firew says the experience has taught her to hone the skill of compartmentalizing — tucking away the Marburg memories so she can continue her work as a physician and mother. But, on this anniversary, she's letting herself relive those first few days and weeks of the outbreak. And she's reflecting on the state of the world today and why it needs the lessons learned from the Marburg outbreak more than ever.
"This is real"
After seeing her colleague, Firew stepped into the hallway and moved to a discreet corner. "I was overcome with emotion — crying," says Firew, who has been practicing medicine for 15 years.
A colleague saw her. "He consoled me. He hugged me," Firew recalls.
She went home to put her kids to bed. They read and prayed for the colleague's "ouchie." Then another text arrived — from the colleague who'd comforted her: "I've developed a fever. I'm in an isolation unit."
Soon another message lit up her phone: The young nurse had died, leaving behind her partner and a toddler.
"That's when I was like: Oh God. This is — this is real," Firew says.
Her mind was racing. She knew that Marburg was deadly, that it had no approved treatment and that it was very contagious, spreading through bodily fluid — even sweat. Closing her eyes, she replayed that hug in the ICU hallway. What if she'd been exposed to Marburg?
"It was just extremely scary," she recalls.
Half her mind was working on her emergency department's strategy for such a deadly disease. The other half was preoccupied with an urgent question: What should she do about her children?
"Telling a 1-year-old and a 3-year-old: 'Stay in a corner. Don't touch me!' was not going to fly," she says.
And her husband wasn't able to help. He was stuck in the U.S. An engineering consultant, he'd gone there for work and dropped by his parents in Atlanta for a quick visit. Then came Hurricane Helene. "He couldn't even get out of his parents' house because there were trees everywhere," Firew says.
She realized she had no choice but to send her kids away. They flew to Ethiopia, where her parents live, accompanied by an adult cousin and nanny.
All the while her phone was dinging with messages from colleagues who were developing symptoms. "They would go isolate. They'd test positive," she says. "And then, especially in the first three, four days, most of them died."
"Mommy, I need you"
Firew had decided not to tell her parents about the Marburg outbreak. She didn't want to scare them. Instead, she said something vague about sending the kids for an Ethiopian holiday. But the day after the kids arrived, her parents called. It was about Firew's 3-year-old: He'd developed a fever.
"Of course, I freak out," Firew says.
Could she have infected her son? The young boy gets on the phone, Firew remembers his words: " 'Mommy, I need you now. Where are you? Why are you not with me?' "
For a moment, Firew says, she let her emotions clouded her judgement. She bought a ticket to Ethiopia. Then she canceled it.
The grandparents took him to the hospital and Firew went to her own hospital, where Rwandan health officials had already set up Marburg testing.
She got tested and, since she didn't have any concerning symptoms, she went to work. She put on full protective gear — stretching it here and swimming in it there since it was not designed for female bodies. Soon she was caring for Marburg patients, including the colleague who'd given her the hug in the hallway.
"He was on the verge of dying," she recalls. "The course of the disease, for me, was extremely shocking. I called it the kiss of death. There's bleeding from the mouth, and other orifices" — their gums, their nose.
"Hearing voices"
The fear followed Firew home that night, where she called up a good friend, Dr. Craig Spencer, who'd lived through Ebola and was himself infected. She remembers telling him, "I can't think clearly right now. My colleagues are dying every day. Could I be next?"
Spencer urged her to think through the practical steps. So Firew upped her life insurance policy. Asking herself: If I die, how much will my family realistically need?
After five days, Firew had hardly slept. Alone and exhausted in her empty house, she says, she started hallucinating. "I was hearing voices. It was voices of my colleagues," she says. "Right when I'm about to doze off, they'd wake me up."
The most vivid voice is that of her colleague who'd given her that hug. She hears him calling her name, repeatedly. She hears the beeping of the hospital machines that are working to save him.
"It was just a complete nightmare — I mean, that's an understatement," she says.
Still, the next day, she got up and went into the hospital where she was running the clinic and had a long list of patients. She went despite the fact that relatives, who'd seen what was happening on the news, begged her not to go. They urged her to leave it all behind for the sake of her kids, her family.
"No Marburg deniers"
But Firew was adamant. She could not leave. Her test had come back negative. She did not have Marburg and neither, it turns out, did her son. He had tonsillitis and would be fine. She had to keep doing her part, she told them.
Part of what made her so resolute was the contrast she felt between this outbreak and her experience as a doctor in New York City during the height of COVID. That time, she says, she felt like the U.S. government was sometimes working at cross purposes with the medical community. This time, she felt, the Rwandan government was working hard to do things right.
It had set up testing and isolation wards right away. It started a clinical trial for a Marburg vaccine within 10 days of declaring an outbreak. And there were plenty of gloves and protective gowns.
"They were no Marburg deniers. There were a lot of COVID deniers," she recalls thinking.
Firew had an idea to do something never before tried for Marburg: Start people who'd been exposed to the virus on an experimental treatment — remdesivir — even before they had symptoms. Remdesivir is a drug Firew used often when she was a physician in New York during COVID. She knew it was safe and was being used experimentally for Marburg in non-human primates. But why not start it prophylactically, in the hopes it could guard against the disease or lessen the virus's impact when it strikes?
"The idea was bought on that Tuesday. It was started on that Wednesday, and we gave it to over 150 health care workers that had high risk exposures," she recalls, saying the research on the impact is ongoing.
Her colleague, the one from the hallway, is among those who came back from the brink. In another experimental procedure run by the World Health Organization and others, Firew and colleagues gave him the first ever infusion of monoclonal antibodies for a Marburg patient. That monoclonal antibody — which was given to others too — was designed to bind to the Marburg virus and neutralize it.
"Just to be part of this extraordinary response is such a big — I guess I'll say, a big opportunity," Firew says. She says she the initial fear she felt is now tempered by feelings of pride for the work she did and gratitude for the colleagues she worked alongside and the family members that supported her.
In recent weeks, as Firew looks at the news, she says her memories of Marburg have resurfaced. Watching as scientific facts questioned and public health approaches upended in the U.S., she says, she wishes the world could see Rwanda's response as proof of what a deep belief in science can achieve.
"The discussions about public health can be so discouraging," she says. "But I look back and see: This work, this effort did not go to waste. It is not futile."
She still thinks about whether she could have saved just one more life. But she also thinks about a moment six weeks after the outbreak started, when she and her husband decided it was finally safe for him and the kids to return home to Rwanda.
"My three-year-old, he ran across the airport when he saw me and it was like this prolonged hug — he just did not want to let go of me," she recalls through tears. "It was a feeling that I've never had before."
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