No Time to Lose: A Life in Pursuit of Deadly Viruses (5 page)

We stopped off at the Unilever plantation in Ebonda. The personnel were frantic. They had incredibly high expectations for our visit, and our brief stay clearly disappointed and further upset them. Women were chanting and shouting in mourning around the small clinic; a number of deaths had recently occurred. We met with three frightened Peace Corps volunteers who had holed up at the plantation—blonde American girls, about twenty years old, who were completely hysterical with fear, in floods of tears. My guess was that even without a mysterious, lethal epidemic, the stress they went through on a daily basis, trying to teach English in Ebonda, must have been really quite something. But I had no idea how to handle them. Joel took over, and promised to get them out, and home, on the first available form of transport.

I had a photocopy of the image of the virus that we had seen under our electron microscope in Antwerp, and for some reason it occurred to me to pull it out and show it. This had a fascinating placebo effect on the crowd. I suppose it made the virus seem more real—less supernatural, and perhaps less potent.

Beyond Ebonda the road became almost impassable, barely more than a sinkhole of mud and water, with entire sections washed away by the torrential equatorial rains. We drove through small villages of not more than 10 to 25 huts, snuggling like nests at the foot of the towering tropical trees. About half of the villages had erected barriers to control people’s movements in this time of quarantine. The elders explained that they had done this without any official instructions, just as their elders had done in the time of smallpox epidemics. We asked if anyone in those villages was currently ill; all shook their heads no. There was no way to check whether this was true, but we told them that if anyone fell ill, they should isolate the person as much as possible and seek to get a message to us at the Yambuku mission.

Suddenly after four hours the dirt road opened out into cleared land, with a few dozen huts and some brick houses that bore remnants of paint and red tiled roofs. That was Yandongi, the administrative capital of the subdistrict, a sleepy town of perhaps a thousand people with a few brick houses from colonial times and a few shops with hardly any goods. Oddly, Yandongi was almost the only village in the Belgian Congo to appear in any work of Flemish literature: in the 1960s Jef Geraerts, a colonial official, had written about the more or less soft-porn adventures of an assistant regional administrator in this sad little place, which he bewilderingly described as seething with ecstatic naked dancing and a primal, wild, rich energy.

Then the thick green curtain around the road closed in again, and we advanced with great difficulty until first the coffee plantations and then the church and red roofs of the Yambuku mission appeared, like mirages, in the blinding sunlight. Surrounded by a neatly swept courtyard lined with royal palm trees and immaculate lawns, they seemed surreal. It was difficult to believe that this clean, orderly, even idyllic place was really Yambuku, the heart of the mysterious killer virus.

To the right of the small church lay the building where the fathers lived; to the left lay the convent where the nuns slept, and the school; and behind them was the clinic. In between was the guesthouse, where three nuns, all aged between forty and fifty-five, and an old, white-bearded priest stood outside the door as if they had been waiting all day.

As our group walked up, Sister Marcella, the mother superior, shouted, “Don’t come any nearer! Stay outside the barrier or you will die just like us!”

Although she was speaking French, I could hear from her accent not only that she was Flemish, but also the region that she was from, near Antwerp. (This doesn’t make me a linguist; Flemish dialects are very distinct, and this was particularly the case for the sisters’ accents.) I jumped over the line of gauze bandage that had been strung up to warn away visitors and shook her hand. In Flemish, I said, “Good day, I’m Dr. Peter Piot from the Tropical Institute in Antwerp. We’re here to help you and stop the epidemic. You’ll be all right.”

There was a very emotional scene as the three nuns, Sisters Marcella, Genoveva and Mariette, broke down, clinging to my arm, holding each other and crying helplessly as they all began talking at once. Watching their colleagues die one by one had been an appalling experience. They talked and talked in a rush of relief. They felt, I think, that we had come to save them and, specifically, that they could count on me. I felt so glad that I could speak these women’s language, both in terms of their dialect and their mentality, the attitudes that they came from.

All these women were younger than my parents, but they seemed antiquated. Their voices reminded me of my father’s grandmother, a big, round-faced woman who was known for miles around as Moe Dolf—Mother Dolf. (Her husband, who died in 1921, was named Adolf, so she was Mother of Adolf’s children.) Moe Dolf grew up on a farm near Wijgmaal, a village near Leuven, and she had never been to school. Still, she could count, and she was sharp; she had a hard head and she was a great cook. She owned a tavern in Wijgmaal that doubled and tripled as a dancing hall, inn, restaurant, village shop, and social club for the men from the Rémy factory down the road, which manufactured starch and where one of my great-grandfathers worked as a machinist, and everyone in the neighborhood celebrated births and marriages, and mourned deaths, with a party at Moe Dolf’s place. Her seven children and many descendants—including my father and his mother—all grew up serving beer and waiting tables, and tending to the pig, the chickens, and the vegetable patch out in back.

Sister Marcella, a short but determined woman, appeared to be in charge. She looked and sounded a little like my great-grandmother and she had the same capable hands and broad cheekbones, but she didn’t have that hard-edged scrutiny in her eye or the same sense of brisk energy. Perhaps it was only to be expected, after weeks of fearful isolation, that she seem so drained of life. In any case it was clear that to her I represented a young but valiant rescuer, someone who had come from home to restore things to their proper place. Though I was the youngest, most junior, and quite possibly the most inept among us, we were bound together through the links of language and shared tradition.

Later the sisters told us that they had read that in case of an epidemic, a
cordon sanitaire
had to be established to contain the spread of the disease. They had interpreted this literally, with an actual cord that they strung around the guesthouse where they had taken refuge. They had also nailed to a nearby palm tree a sign in Lingala, warning
“Anybody who passes this fence will die.”
It instructed visitors to ring a bell and leave messages at the foot of the tree. It was scary and sad and spoke volumes about the fear that they had endured.

As Sister Mariette prepared dinner for us, Sister Marcella showed us the notebooks where she had recorded all the deaths of hemorrhagic fever patients, and any data she felt was relevant to their illness, such as recent travel. Nine out of 17 hospital staff had died, as had 39 other people among the 60 families living at the mission, and four sisters and two fathers. She broke down several times as she described their symptoms and the agony of their deaths, particularly those of her fellow nuns. This small group of women, all from the same area northeast of Antwerp, all of whom had been in Zaire for more than six years, had naturally developed a profound bond in this small outpost of Flanders in the equatorial forest.

“We prepared ourselves to die,” she said simply. “We spent our days in prayer.” I knew that to her this was a simple, factual description, but these modest words conjured a suffocating sense of doom, the sense of an invisible disease closing in on a dwindling number of women.

Sister Marcella continued reading out from her neatly kept records as I scribbled down more precious pieces of information. She listed the names of villages where deaths had occurred. She wondered whether the illness might be linked to eating fresh monkey meat: the villagers often foraged for food in the forest and the headmaster who was, tentatively, our “Patient Zero” had returned from his travels with several monkey and antelope carcasses. She noted a high number of deaths among newborn children born at the mission clinic, and observed too a sudden spike in stillbirths among their herd of pigs. Three months ago, she said, there was an epidemic among goats in the region of Yandongi.

These were all good lines of inquiry. (Later I took blood from the pigs through their tail veins, a new experience for me.) None of them panned out exactly, but another of Sister Marcella’s hypotheses proved to be exactly right. “Something strange must be happening at the funerals,” she told us. “Again and again we’ve seen that the funerals have been followed a week later by a batch of new cases among the mourners.”

She was clearly pleading with us for answers, but there was nothing we could say. Our first job was just to ask questions. To break the ice I showed the electron microscope photos of the new virus, as I later did in every village we visited. The sisters too were fascinated by the wormlike structures that had caused so much pain and devastation in their community.

Joel handed over the supplies we had brought with us—essentials such as petrol, but also comfort items: Gouda cheese, beer, some correspondence, and Flemish newspapers. Although we had no authority to do so, we told the nuns again and again that we would not leave them until the outbreak was over. Although we might be going back and forth we would not abandon them.

Pierre suggested that starting the next day we split up into three teams, one per vehicle. Each team would systematically visit as many villages as possible for a preliminary epidemiologic survey, to identify active cases of hemorrhagic fever, to provide whatever basic care we could muster, and to make sure that the patients were kept isolated and, if necessary, buried without the normal rituals, to prevent further spread.

We then briefly visited the hospital, which was made of a few small, square pavilions with red metal roofs, connected by covered walkways, much like the Clinique Ngaliema. Everything was empty: most of the patients had fled, fearing they would be contaminated by the fever, and finally after several of the nursing sisters died the decision was made to close it down completely. The rooms were clean, the blood stains barely visible, but as a medical center it was very rudimentary and the surgical theater was the most basic kind imaginable: a high bed with a plastic-covered mattress. I didn’t see any anesthesia equipment.
How do you do surgery without anesthesia?

With the diesel oil we brought, the nuns started up the mission’s generator so we had some light in the black tropical night. As a feast, they prepared
Carbonnades à la Flamande
, a traditional Flemish winter stew with beer that we settled down to consume in the steaming tropical heat. To me the effect was slightly comic, but I could also see that to the sisters it was almost magically comforting. We had brought beer and wine, and taciturn Father Léon emptied half a bottle of the Johnny Walker whisky that Jean-François Ruppol had brought him. The sisters sipped a few tots of Dubonnet fortified wine, their carefully rationed evening tipple: they seemed to be allowing themselves to relax for the first time since the death of Sister Beata on September 20, exactly one month earlier. They spoke almost endlessly about their families, their religious order, and Flanders.

As we had no clue how the virus was transmitted, and whether the virus could somehow survive on materials such as mattresses and linen, we decided to sleep on the floor of a classroom in the girls’ boarding school, which we first fumigated with formaldehyde and mopped with bleach. I was exhausted, but once again could not sleep. There were too many impressions and questions racing through my head. We had no idea whether the epidemic was still spreading or how fast, but we clearly were approaching the heart of it: soon it would be staring us in the face. I wondered too what on earth happens at a Zairean funeral, and what could motivate a Flemish woman to spend her life in the middle of a faraway jungle, totally disconnected from her world, without the most basic infrastructure and communication. How could you run a 100-bed hospital without even one physician? How did people survive in these villages? How could I be most useful here?

The night was bursting with the caws and cries of animals. I went outside in the blackest of nights, where stars shining uninhibited by city light seemed so close above my head that I might almost reach them, and I listened to the distinct and ominous sound of drumming. Perhaps, in the ancient manner, our arrival was being announced.

CHAPTER 4

Ebola

T
HERE’S A KIND
of excitement that takes over when real discovery is at hand—almost like light drunkenness, but with tingles. Laying on the floor in the Spartan comfort of the girls’ dormitory in a village thousands of miles from anywhere any member of my family had ever reached, I knew that this was a defining moment in my life—scientifically, geographically, in terms of every kind of emotional and physical horizon. I was facing a total unknown: a new virus, a new continent. Even the insects were monstrously unfamiliar, the cockroaches as long and fat as my finger. But I had no room for fear or worry. I felt
alive
.

The next morning—Thursday, October 21—the nuns introduced us to the only two known survivors of the mystery fever. One was the wife of the deceased headmaster of the mission, our Patient Zero. “Mbuzu ex-Sophie” was a small young woman with hunched shoulders. (President Mobutu banned Christian names, forcing everyone in Zaire to take an African name; those who continued to use their previous identities were obliged to camouflage them behind the prefix “ex.”) Her head was shaven (I learned in Bumba that mourners in this region commonly shaved their heads) but she was quite robust, and though she had clearly been ill she reported only a high fever, headache, fatigue, vomiting, and diarrhea, no bleeding or other signs of internal hemorrhage. Sukato, a male nurse at the hospital, reported a similar set of symptoms, and although he was extremely thin there was no way of telling whether that was due to his illness.

It was a real relief to find two healthy convalescents so quickly. If we could confirm that they really had been infected with the mystery virus—and if we could persuade them to act as donors—these two former patients could provide the precious plasma that seemed to be our only hope to treat other victims of the disease. The problem, however, was that our plasmapheresis equipment was still in Kinshasa. We would also need to test their plasma before using it, to be sure that it didn’t contain live virus, and these tests would require specialized material operated by highly qualified researchers working in an extremely safe environment—a virus lab like the one at the CDC in Atlanta. It would not be easy to transport potentially highly lethal substances to Atlanta from Kinshasa; from Yambuku, or even Bumba, it just could not be done. In other words, we would have to persuade these two villagers to travel back to Kinshasa with us when we left. We broached the subject: Sophie, who had lost two of her eight children to the virus, as well as her husband, rejected the option immediately. She initially didn’t even want to give blood, though she wanted to help.

We needed to get out on the road before the midday heat and afternoon storms made travel very hard. Leading out from Yandongi, there were four roads we could follow (though they were not “roads” in any Belgian sense), and we had four cars: one that we had brought from Kinshasa by plane, one that Father Carlos had given us from the mission in Bumba, and two that belonged to the Yambuku mission. This meant we could split up. Our objectives were pretty basic. We needed to know whether the epidemic was still active, and if so how active it was and how extensive its geographic spread. The only way to learn these things was to go out and look for clues. We also needed to nail down a preliminary sketch of possible risk factors and, of course, the mode of transmission. And we also needed to take blood samples from the sick—as many as possible—because so far we only had one sample of the virus and we needed to confirm it.

I was to travel with Pierre Sureau and Sister Marcella, the mother superior, in her ancient Land Rover. We would take the road west. We were also planning to act as “firemen,” on call for the other teams, though we had no communication equipment whatsoever with us. To reduce the number of people exposed to the risk of contamination, Pierre and I would be the only ones to take blood from acutely ill patients.

The forest erupted with noise like a living thing as we hurtled and lurched our way along the well-trodden paths. At several points we came across barricades—huge branches and bamboo sticks slung across the roads. Although the whole zone was supposed to be under official quarantine, Sister Marcella said that the village elders had received no orders from the medical or military authorities to build these obstacles; they were prompted by old knowledge, ancestral memories of experience with smallpox epidemics that had periodically devastated the region before being eradicated in 1979. These barriers were mostly manned by small children and the elderly; many of the older men and women were smoking pipes that smelled strongly of marijuana. Seeing Sister Marcella they acquiesced and let us pass.

The villages were closely nestled hamlets of mud huts with banana leaf roofs. Outside them, wispy cooking fires burned all day under their dried-leaf awnings. We were quickly surrounded by villagers. There was no doubt that every person we saw, in every village that we went to, had heard about the killer epidemic. Just about every village had suffered at least one death. We took down as much information as possible about those cases and how they were cared for, noting that in almost every case the corpse was buried right behind his or her hut. In addition, there seemed to be no quarantine or precautions other than the barricades, and those were clearly less than total: people spoke freely of family members traveling to other villages to care for their loved ones.

Still, in the first few hamlets the chiefs reported no active cases. I was suspicious but felt that surely they would have no reason to hide a dying patient.

Then after perhaps five or six villages, we were brought to a hut where two patients lay: man and wife. We were told they had been sick for several days. Standing outside the small hut, we robed in our protective gear, with gloves and gown and motorcycle goggles and paper surgical masks. We had been equipped with full-face respirators that provided airtight isolation, and thus better protection from airborne virus particles, but they were suffocatingly impossible to wear in the midday heat. It was the first time I had ever entered an African village home, and in this astronaut gear I was certainly as much of a shock to its inhabitants as they were to me.

The sick couple lay on raffia mats, piled on top of a low platform made of branches. Flies settled insistently on the black crusted blood around their mouths, noses, and ears. Both had dark blotches on their torsos and their eyes were darkly bloodshot. They had barely the strength to move. The husband began vomiting blood, painfully and spottily. Both had a look in their eyes that I later became familiar with in AIDS patients but had never seen before. It is an empty look, a ghostly deadness that some people describe as “glassy-eyed.”

With easy, skillful gestures of care, Pierre Sureau slipped over to the bed. He nodded an attempt at reassurance and slipped a syringe into the woman’s arm. I merely watched; I had no idea how to be useful, for I knew we had no possible treatment to offer these people. We had supplies of tetracycline, a broad-spectrum antibiotic, and loperamide, a strong antidiarrheal, but neither of these was going to help.

As Pierre drew the blood out of the wife’s arm, her husband gave one last strangled choke and then stopped breathing.

I had seen dead people; in medical school I had
cut
dead people. And occasionally patients had died in various hospital wards where I had worked as an intern, as well as violent deaths during my work in the emergency room in Ghent in Belgium. So I had thought I was inured to dying. But most of those had been
sedated
deaths—unfortunate, sure, but sanitized, predicable. Watching someone die in front of me was new.

Both Pierre and I froze: How would the other villagers react? Would they assume that in our nightmarish outfits we had killed this young man? I glanced at Pierre and saw that he, too, was shaken, and the same thought flashed through both of us: if the man had died while Pierre was taking his blood, we would quite possibly be killed. We explained what had happened and left as soon as possible, giving instructions that the bodies should be buried immediately, without any cleansing or ritual, and should only be touched with gloves (we left several pairs in the village).

That morning we saw eight sick people, though none as obviously close to death as the first couple. All had the glassy look in their bloodshot eyes, severe abdominal pain, and bleeding from various orifices. We also saw a number of people who reported that they had suffered what seemed to be an attenuated version of the disease, with swollen face, severe headache, high fever, and chest and abdominal pains, but no hemorrhage. We asked them to allow us to take blood for antibody testing. This was difficult: they seemed convinced that witchcraft of some sort was involved, and it fell to Sister Marcella to persuade them.

Although they seemed reluctant to discuss this in front of Sister Marcella, most of these people attributed their recovery to the intervention of the
nganga kisi
, the herbalist or sorcerer. Pierre and I both noted this, and later discussed the obvious difficulties of asking people for information while using as a translator a person who for religious and medical reasons was so obviously likely to disapprove of certain answers.

We returned, stunned, to the mission in torrential rain, churning with difficulty through the sodden jungle paths. A midafternoon meal was waiting for us. I don’t remember exactly what it was, but the sisters ate largely African food:
foufou
porridge; local rice; goat or chicken or game from the forest. Once we even ate monkey—a dish of
carbonnades,
a quintessentially Flemish stew made with fresh monkey meat, probably from a vervet,
Cercopithecus aethiops
, as we were informed when the meal was over. Since we considered monkey a possible vector of the disease, this was perhaps not the most prudent of choices. But we found it hard to be rude to our hosts, and I reasoned with myself that the meat was so extremely overcooked that surely no virus would remain active.

Later that first afternoon, Sister Marcella called the order’s mission in Lisala on the crackly old ham radio that was Yambuku’s only connection to the outside world. Her colleague in Lisala passed on a message to us from Karl in Kinshasa: Mayinga, the young nurse whom we had visited at the Clinique Ngaliema, was dead. In other words, the Marburg plasma that Margaretha Isaacson had brought with her from South Africa did
not
deliver protection from our epidemic.

That evening there was a new sense among us of the gravity of the situation. A real camaraderie had sprung up among us. Joel Breman from the CDC was our leader—an experienced field epidemiologist, a veteran of smallpox, with a great sense of humor. Pierre Sureau, too, was a real inspiration to me. A chain-smoking fifty-year-old who had more experience in his left elbow than I had in my entire body, he nonetheless was never snide or scornful, indeed treated everyone with the same gentle courtesy. Dr. Masamba, the regional director of public health, who joined us in Bumba, was an excellent organizer, and he seemed impervious to fear. The Belgian Jean-François Ruppol took care of logistics. He spoke Lingala and Kikongo, having grown up in Zaire on his parents’ cattle ranch, and he was a good man in a pinch.

Sitting around our lamplit dorm that evening, it struck me that the scene was a little like in those jokes where a Belgian, an American, a Frenchman, and a Zairean might all walk into a bar.

FOR THE NEXT
two days we toured villages every morning, taking blood where we could, jotting down every potentially telling detail and piece of data we could muster. We saw patients with blood crusting around their mouths or oozing from their swollen gums. They bled from their ears and nose and from their rectum and vagina; they were intensely lethargic, drained of force.

In every village we organized a meeting with the chief and elders. After the ritual passing of a plastic cup of roughly distilled
arak
—banana alcohol, which Pierre had the courage (or perhaps the common sense) to refuse—we asked them to describe their experience of the new illness, the number of cases and deaths, the dates, whether they had knowledge of any people currently sick. We questioned every villager we came across about day-to-day practices—unusual contact with animals, new areas of forest cleared, food and drink, travel, contact with traders.

We heard of entire families who had been wiped out by the swift-moving virus. In one case, a woman in Yambuku had died days after giving birth, swiftly followed by her newborn. Her thirteen-year-old daughter, who had traveled to Yambuku to take charge of the child, fell ill once she returned to her home village and died days later; followed by her uncle’s wife, who had cared for her; then her uncle; and then another female relative who had come to care for him. This extremely virulent interhuman transmission was frightening.

We were all familiar with our terms of mission: we were here just for three or four days, to act as scouts in preparation for the arrival of a larger team that would try to set up systems to control the epidemic and break ground for further research. Our job was to document what was going on, sketch out some basic epidemiology, take samples from acutely sick patients, and, if possible, find recovering convalescents who might provide plasma to help cure future sufferers.

And we were doing that job—harvesting samples, collecting data, and cataloging the basic logistical equipment that the larger team would need to bring. But we knew that from a human point of view this simply wasn’t enough. We needed to stop the virus from infecting and killing people.

The mystery fever’s epidemic curve was starting to take shape. The classical epidemiological curve is pretty simple; it plots the number of new cases of an infection against time. In the simplest type of outbreak the number of people infected rises gradually, then picks up pace, reaching a peak at the midpoint of the graph. Once the virus has exhausted its stock of easy victims (the weak or easily accessible), the rate of new infections begins to wane until the epidemic fades to a whisper.