No Time to Lose: A Life in Pursuit of Deadly Viruses (10 page)

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PART TWO
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CHAPTER 7

From Ebola to Sex and t
he Transmission of Infection

W
HEN WE RETURNED
to Europe, Guido and I paid a visit to the convent of the congregation of the Sacred Heart of Our Lady to give the sisters a full report. S’Gravenwezel is a small town north of Antwerp, and the huge convent was an extraordinary place, very formal and grim; it felt like another era. We arrived at the appointed time one dark, almost-snowing afternoon in January. We rang a large bell and the heavy convent door slowly opened. A sister walked us through a series of freezing cold corridors to a waiting room. Finally we were called on to speak before the mother superior and all the assembled nuns.

I almost expected candlelight. I once again marveled at the series of historical events that had projected these women into a tiny village in Central Africa. You could hear a pin drop when we reminded them how the four sisters had died, and they asked too many questions to which we had no answer. We discussed also how we could raise money to refurbish the hospital, and they were very keen to recruit a doctor for Yambuku. Even after our presentation I’m not sure that the implications, in terms of their responsibility for the epidemic, had really sunk in. They profusely thanked us and said that they would pray for us, and then we focused on raising money for Yambuku.

This made me feel we hadn’t done our job, frankly. Guido insisted that we shouldn’t underscore their guilt: he saw their heroism and goodwill, their dedication, and loved them for it. But I thought it could have been an important lesson. Goodwill is not enough. You need to be competent, you need to know what you’re doing, or you may do more harm than good. To be fair, it was true that they had had very little funding, extremely poor training, and they had not been able to pay for any doctors in the Yambuku hospital. Thus we promised to help them ask for government money so they could pay for a doctor at the mission. But I couldn’t help wondering how many more mission hospitals in Africa were as underequipped and poorly run as Yambuku, and what earthly difference one doctor could make.

I was feeling sobered about the whole experience of traveling to Zaire. Maybe it was a kind of postcombat depression. I saw how irresponsible we had been throughout the whole assignment. No insurance, as traveling to an epidemic zone was an “extraordinary risk,” against which the institute had not insured employees. No evacuation plan: the Americans had one, and all we did was rely on their probable help. Post hoc, I felt scared and angry at the scale of the risk.

I was also furious, because Pattyn without intending to do so, tried to deprive me of my reward. I was one of fewer than ten doctors who saw a case of Ebola; I participated in isolating the virus. One afternoon I walked into his office and saw on his desk the manuscript of the article he was writing to report the discovery of the virus. Neither my name nor Guido’s was on it.

In a sense, this was how things often had worked in science in Europe until the 1970s: the young people did the work, and their bosses took the credit. Pattyn wasn’t doing anything unusual, but it really made me mad. I grabbed the paper, went to find Pattyn, and calmly told him, “I am going to be an author of this article and Guido is going to be an author of this article!” Pattyn simply dissolved. He blinked a little bit and mumbled something about it being just a draft, after all, and wrote our names in right there while I was watching.

It felt like a small victory, however. Work at the lab seemed routine. My life—despite the comfort and friendliness and safety of it—paled in comparison with the drama of Ebola. A number of us must have felt the same way, for when the World Health Organization (WHO) convened a meeting of the international commission that month of January 1977 at the London School of Hygiene & Tropical Medicine, there was a tense and scornful dispute between the Zaire team and the group from Sudan—one that seemed way too emotional for its supposed subject. This was my first formal international meeting, and despite all the rituals of each speaker taking the floor and formally thanking everyone, there was tension. Each team accused the other of poor statistics. Ebola had killed only about 50 percent of its victims in Sudan, whereas the figure in Zaire was far higher, more than 80 percent. Later on it turned out that the two strains of the virus were different: almost unbelievably, there had been two simultaneous but unrelated outbreaks of the same, previously unknown disease within a radius of 500 miles. Again, there was a lesson here: something that may appear to be completely unlikely—even ludicrous—can happen.

The London School was an imposing establishment near the British Museum, its building nearly a whole city block, lined with the names of famous physicians of tropical medicine, which seemed to radiate all the imperial power of the British empire. Little did I dream that I would much later be appointed to direct this august institution. Too intimidated to speak much, I listened as my colleagues agreed on a number of recommendations for WHO. The main proposal was that mechanisms should be developed to identify and react promptly to new outbreaks of hemorrhagic fever, with mandatory reports to WHO of all new suspected cases, a Disaster or Outbreak Fund, and a constantly updated list of experienced people ready to participate in a rapid deployment team. We also recommended training for people who would coordinate expeditions; specific operational plans for surveillance, epidemiological studies, lab support, logistics, communications and information to the public; lists of the kinds of specimens needed for differential diagnosis, and where to send them; and a special, detailed checklist of recommended supplies. Basically none of it was ever implemented.

A few weeks later in February Pattyn received a phone call. The Ebola epidemic had perhaps flared up again in Yambuku and this time it might have already spread—maybe even to Belgium. Days before, a patient at the Yambuku hospital—a farmer, with a small shop—had developed what the sisters identified as Ebola symptoms and died. The nuns panicked. Rather than endure more weeks of quarantine and a continuing drumroll of deaths, they bolted to Kinshasa and caught the first available flight to Belgium. They were currently at the convent, consumed with fear.

Pattyn and I went to s’Gravenwezel. The sisters began crying. They could see that in taking flight they had not only abandoned what they conceived as their duty, but they had also potentially endangered other people. (They seemed to have posttraumatic stress syndrome—not surprising given what they went through.)

Then he turned to me. Pattyn wanted me to go back to Yambuku. He said that “we” would do the job
without
the Americans this time. “We” would get in there and find Ebola’s natural reservoir.

I flew into the zone with Jean-François Ruppol and Dr. Weyalo, a young Zairean internist from the Clinique Kinoise, a brave and good companion. We landed in Gbadolite, the home village of President Mobutu’s mother. Here Mobutu was engaged in erecting a series of three palaces—actually an entire Versailles—in which he and his wife (whose name, amazingly, was Marie-Antoinette) could indulge in his favorite tipple, vintage pink champagne.

Seen from above, the fake lakes and curving balustrades of this Italian-marble confection were simply obscene, a megalomaniac Disneyland that was emblematic of Mobutu’s theft of resources and his distance from his citizens’ concerns. The airport—equipped for intercontinental jets—was huge and empty. Leading from it, a four-lane highway lined with European tulips led past a number of villas said to be under construction for various dignitaries of Mobutu’s régime, all of them jostling for proximity to the
Président-Fondateur
. Colonialism surely wasn’t much worse than this loathsome régime.

We drove to Yambuku. The whole region was in panic. The mission hospital was deserted, though Sukato, the nurse who had survived Ebola infection, was still there. We stayed for two weeks, from February 7 to 20, trying to develop a clear picture of events. Everywhere we went it seemed much more like an outbreak of rumors than an outbreak of disease. Although the sisters were now using sterile needles for injections, we followed up every possible needle contact we could; none seemed to have an infection. At every village we went to, people said, “Here there have been no deaths”—they were absolutely certain of that—“but in such-and-such a village the fever is back.” But when we went there to check it out, we found nothing.

It was in a way more difficult to investigate a nonevent than an event. You had to prove that something
hadn’t
happened. We wondered if people were hiding the disease so as to avoid the crippling economic effects of a quarantine, but we reasoned that this would have been a lot to hide. And there were other clues too. I saw no women with shaved heads, and I knew that meant there had been no deaths. People would not give up customs that ran so deep just to fool a couple of doctors. In the meantime we held consultations, and even did some emergency surgery, since the hospital still had no doctor.

In the end it was up to Dr. Weyalo and me to decide whether to quarantine the whole region. And we concluded that there was no need to do it. A single man had died following rectal bleeding. Probably he had had colon cancer. But in a region still seething with fear and tension months after a murderous epidemic that was all it took to ignite a new, quite pointless wave of terror.

I RETURNED TO
Antwerp, a tolerant city in these days, and my son Bram was born in April, a few weeks after my return. To my surprise I found that this completely predictable event suddenly shifted my whole view of the world. Before, I felt completely independent. Now someone was relying on me, and a certain insouciant self-indulgence had to give way; I felt responsible, even anxious, about my—
our
—future. During the long evenings in Yambuku, Joel Breman and I had talked about my plans. I wanted to do more training in the United States. In Yambuku I grasped just how far ahead American medical science truly was. I was particularly impressed by the synergy between several disciplines to tackle a problem, and by the highly critical review of every step in the research process. And there was a joke in Belgium that if you wanted to get anywhere in academia, you needed the BTA diploma—Been To America.

Joel said that he would get me a place at the CDC’s famous field epidemiology program, the Epidemic Intelligence Service course, which in those days took very few foreigners. But I knew he couldn’t bankroll that; I would have to find the money. Pattyn, meanwhile, urged me to finish my specialty training in clinical microbiology. So while I was applying for various fellowships and sponsorships I continued working at the institute.

But then that spring a new adventure presented itself. André Meheus, a professor of epidemiology at the University of Antwerp, contacted me: he needed someone who knew about lab techniques to accompany him to Swaziland on a mission for WHO. I knew Meheus from my days as a medical student in Ghent; I was then an intern in the Department of Social Medicine where he worked. He was an easygoing and likable man with a lot of contacts, and somehow he had persuaded WHO to fund a five-week mission to southern Africa so that he could eliminate sexually transmitted disease from Swaziland.

When I heard this absurd premise I choked. But André told me this kind of thing was almost routine. WHO made up terms that were deliriously unrealistic and to receive funding you had to promise to fulfill them. But nobody ever checked whether you had achieved the impossible results you’d promised, and so long as you did some work and pushed the buck a little further down the road, everyone was happy. (Incidentally, at today’s WHO this particular attitude has greatly changed.)

It was cold in Swaziland in June—the Southern Hemisphere’s winter. The country was very different from Zaire. There wasn’t the same exuberance of nature—in all its greenness and wilderness—or the same vivid personal style in terms of the way people dressed and moved and spoke. Zaireans were desperately poor, but they looked colorful, elegant, with elaborate hairdos and joyful gestures when they spoke. In Swaziland people were also very poor and were dressed in dingy sweaters.

They also had a stiffness about them, and a sadness that I interpreted as the shadow of apartheid: people, particularly men, seemed to have been somehow broken. Even men over sixty were routinely hailed as “Boy.” It was strange, miserable, ugly. But after a while, I understood that these people were as warm as those in Central Africa, just different. Swaziland was a monarchy with an absolute king. South African police were said to be everywhere, supervising everything, so that the exiled African National Congress liberation movement couldn’t use the country as a base of operations. But many whites whom I met at the hotel seemed to be present for two things only—to have sex and to gamble.

In those days I knew hardly anything about sexually transmitted diseases (STDs). But André and I went to clinics, estimated the numbers and type of sexually transmitted infection, reviewed their treatment guidelines (which were almost uniformly ineffective), and saw—it was clear—that the STD problem in Swaziland was enormous. I noticed when I was going through the mission records in Yambuku, and at the Mama Yemo Hospital in Kinshasa, that there seemed to be a sexually transmitted disease problem in Zaire, too; chancroid and salpingitis and urethritis and gonorrhea seemed to figure far more often than I would have expected in Belgium. But in Swaziland, the scale was off the charts.

We were doing clinical examinations, of course. And the kinds of complications and combinations of STDs that we were reviewing were simply mind-blowing. Every clinic was like a museum of genital disease, a cabinet of sexually transmitted curiosities. The patients were all desperately poor. A man would walk in wearing his skirt and you would see that his penis was dripping on the floor. He would pick his skirt up, show me a truly monstrous chancroid, and I would ask, “So when did you last have sex?” And he would say, “This morning.”