The Anthrax Letters: The Attacks That Shocked America (18 page)

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Authors: Leonard A. Cole

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The transmissibility of the spores prompted health and law enforcement authorities to use a new term that gained quick and frightening currency: cross-contamination. From the time that the first anthrax letters were processed on September 18 through the time that the Hamilton and Brentwood buildings were closed, 85 million pieces of mail were handled at the two facilities. They were bound for destinations in every state of the union and in countries around the world. No one knows how many letters became cross-contaminated, but it is likely that thousands, perhaps millions, might have carried some anthrax spores. Yet few people showed evidence of infection. And in the known cases, at least the source of infection could be traced to infected mail. Stephen Ostroff, chief epidemiologist for the CDC, described the feeling among his associates: “I think in the back of everybody’s mind was the question, ‘What’s the potential for massive risk?’ Still, it was comforting that all the exposures were explainable.”

But if massive infections never materialized, the comfort about explainable exposures was short lived. In due course, two more anthrax cases were identified, each without a clue about how the victim was exposed.

chapter five
 
 
The Outliers

T
he sound of salsa music floats into the lobby from a ground-floor apartment at 1031 Freeman Street in the South Bronx. The 30 brass mailboxes in the entranceway largely bear Spanish-sounding names like “Espina,” “Rivera,” and “Rodriguez.” The name on the box for Apartment 3R, “Nguyen Xinh K,” is an exception, not only because the name is Asian but because its bearer is no longer alive. A month after Kathy T. Nguyen’s difficult death from inhalation anthrax on October 31, 2001, her Vietnamese name remained on her mailbox.

Kathy’s mailbox was interesting for another reason as well. Investigators had found no trace of spores in her clothing, apartment, workplace, or mailbox. Still, a nagging suspicion remained that her death was somehow connected to the mail. After all, until then every instance of anthrax infection since the 4-week-old outbreak began had been traceable to mail.

Above the row of mailboxes was a picture of Kathy, faintly smiling. It was posted beside a request by the FBI, the police, and the New York City Department of Health: “Anyone who saw her or knew of her movements and activities between October 11, 2001 and October 25, 2001 please call the Task Force Hotline: 646-259-8539.” In the weeks after Kathy’s death, the hunt for the source of her infection became intense.

Kathy had arrived in the United States in 1977, a refugee from the collapsed South Vietnamese regime. Since 1990 she had worked at the Manhattan Eye, Ear, and Throat Hospital on the Upper East Side, where she delivered supplies from the stockroom to the clinics and operating rooms. Adored by neighbors and co-workers, this small unassuming woman could not know that at age 61 her last desperate breaths would define her tragic celebrity.

“Dave, I’m not feeling well. It hurts to breathe,” Kathy said late Sunday morning, October 28. Dave Cruz had managed the Freeman Street apartment complex since 1981 when Kathy moved there. Her words were still fresh in his mind weeks after her death. From his storefront office around the corner from the apartments, Dave shared his thoughts and his sadness. A husky figure wearing a T-shirt, he has a surprisingly soft voice. Kathy lived alone. She was undemanding, he said, paid her rent on time, kept her apartment spotless. “You couldn’t get any better than that.”

Dave was already on his way to Kathy’s apartment that Sunday morning when they encountered each other in the courtyard adjacent to the building. One of his workers had found him to say that Kathy was urgently looking for him. When he saw her he asked, “Would you like to go to the hospital, Kathy?” thinking of Jacoby Hospital a half mile away. “Yes, but please take me into Manhattan to Lenox Hill.” Dave rushed for his minivan.

Lenox Hill Hospital is on East 77th Street, 13 blocks north of its smaller subsidiary, “Eye and Ear,” where Kathy worked and where elective surgery was the principal fare. Kathy’s own physician was on the staff of both hospitals. After a decade of commuting, she knew the area well. Her trip to work ordinarily began a block from her house at the Whitlock Avenue subway station. Twenty-five minutes on the Number 6 train to the East 68th Street Station put her just 5 minutes by foot from work.

But that Sunday, Dave reduced her usual commute time by a third: through some traffic lights along Bruckner Boulevard, over the Third Avenue Bridge to Manhattan, and a final uninterrupted stretch along the FDR Drive. As he drove, barely aware of the sun’s reflection off the East River, Dave remained focused on Kathy. He was incredulous when she tried to hand him money orders for 2 months’ rent—in case of a long hospital stay, she said. “Put them back in your purse, and don’t worry about such things now.” Kathy’s labored breathing prompted questions. Did she have asthma? Bronchitis? he asked. “No, no, it just hurts.” He tried to reassure her: “Don’t worry. Maybe they’ll give you antibiotics.” At 11 a.m. they arrived at the emergency room, and he walked her into the examination area. Dave Cruz did not know what else to do except give her his business card and a word of assurance before leaving. “Kathy, please call me if you want anything.”

Dr. Mayer Grosser spends much of his time in a short-sleeve green shirt, the pajamalike top of standard hospital garb. A 13-year veteran of Lenox Hill’s emergency room, he is used to seeing people in distress. Kathy’s case did not seem extraordinary. She described her symptoms—chest pain and shortness of breath that had worsened during the previous 48 hours. He put his stethoscope to her chest and back and heard crackling sounds across her lungs, an indication of fluids. “Rales,” he thought to himself. A chest X ray also suggested pulmonary edema, the presence of fluids in and around the lungs, all of which he thought pointed to the probability of congestive heart failure.

Kathy worried that her illness and her absence from work would cause some inconvenience to her employer. “How can we get in touch with my boss?” she wondered. “I have to tell him I’m not going to work tomorrow.” “Don’t worry,” Dr. Grosser assured her. “We’ll take care of that.” Meanwhile, he pondered over her medical history. The only hint of abnormality was her elevated blood pressure, but that was under control with daily pills. After a few hours on nitrates and a diuretic for presumed heart failure, there was no improvement. An echocardiogram later confirmed that she had no heart abnormalities.

About 5 p.m. Grosser looked again at her chest X ray. “I saw the widened mediastinum and it hit me. I thought, ‘This could be anthrax.’” He asked her if she worked near the mailroom. “Yes,” she said and explained that the mailroom was attached to the central supply room. “I never mentioned the word ‘anthrax,’ and she didn’t either,” he said. “But she was a smart woman and she became visibly concerned after that.” By then he had her taking large doses of Levaquin, an antibiotic in the ciprofloxacin family. At 7 p.m. Kathy Nguyen was moved to intensive care.

By the time Dr. Bushra Mina saw her at 9 p.m., Kathy’s breathing was more difficult. She was lucid but told him she was very tired. Mina, a pulmonary and critical care specialist, was aware of Grosser’s presumptive diagnosis. Slightly built and soft spoken, Dr. Mina recalled how worried he was about Kathy’s unusually rapid deterioration. “She seemed to be weakening by the minute,” he said, and he ordered an intubation tube to help her breathe. Inserted through her nose into her trachea, the tube also prevented her from speaking. Around midnight she seemed stable, and Mina went home for a few hours of sleep.

When Dr. Mina returned at 6 a.m., he had Kathy sedated while he performed a bronchoscopy, which enabled him to peer into the small passageways that branched throughout her lungs. His viewfinder became immersed in bloody, infected fluids. During the remainder of the day, despite placement of tubes to drain the fluids from her chest, her condition worsened. She lapsed into unconsciousness, and her organs began to fail.

Meanwhile, on that same day, Monday, the results of testing at the large Morgan mail distribution center at 9th Avenue and 29th Street in Manhattan were announced. Five of the sorting machines had small amounts of anthrax, though no postal workers had become infected. The letters that had caused the seven cases of anthrax in the New York City media offices apparently had been routed through those machines. The two recovered letters, to NBC and the
New York Post
, had first been processed on September 18 at the Hamilton center in New Jersey and then forwarded to Morgan.

Now, the news about Kathy’s inhalation infection unnerved everyone. Could she have been exposed to anthrax from cross-contaminated mail that, 40 days earlier, had gone through Morgan? Was a new attack under way? The New York Metro Area Postal Union urged that the Morgan facility be shut down. But the postal authorities closed off only the contaminated sections on the second and third floors. David Solomon, a postal service spokesman, said the building would remain open because “health professionals [have not said] there is a health danger for our employees.” Still, workers were worried. The absentee rate at the facility climbed to 30 percent.

As word circulated in both hospitals about Kathy’s anthrax, anxiety among hospital personnel also rose. At the request of the city health department, patients from Manhattan Eye and Ear were moved out and the hospital was closed. A week later, after no anthrax had been found there, the hospital reopened. During the closing, 250 surgeries were canceled, and by the end of the week the hospital had lost about $1 million in revenue. Dr. Thomas Argyros, the medical director at Lenox Hill, recalled the atmosphere at the time:

The dynamics were terrifying because of the possibility that she got the anthrax at the hospital. Anyone who had been in Eye and Ear since around October 15 had to go for prophylaxis. About 2,000 people were screened here [at Lenox Hill] and at [nearby] New York Hospital, and they went on antibiotics.

 

One of the people screened at Lenox Hill, Daisy Cruz, had been to the Eye and Ear Hospital on October 18 for a hearing test. At her screening for anthrax, she said that she was “crazy” with fear: “I see anthrax in the toothpaste. I see it in the orange juice. I see it in the sugar. They’re going to kill me with a heart attack before they kill me with anthrax.”

 

The New York City Health Department first heard about Kathy Nguyen on Sunday night, October 28. Dr. Michael Tapper, head of infectious diseases at Lenox Hill, had called Marcelle Layton, the city’s assistant health commissioner. “Marci, I think we have a problem. I think we may have a case of inhalational anthrax.” The next day members of her staff joined with law enforcement officials to speak with the staff at the hospital. Among those who went to the hospital, Timothy Holtz and Joel Ackelsberg became the lead epidemiological investigators for the case. Dr. Holtz had arrived in New York only 2 months earlier as a temporary “preventive medicine fellow” from the Centers for Disease Control and Prevention. Dr. Ackelsberg had just joined the department in 2000 as its coordinator of bioterrorism preparedness.

Holtz and Ackelsberg are contrasting figures in appearance as well as background. Holtz’s closely cropped, fire-red hair, mustache, and beard seem out of phase with his laid-back demeanor. His baritone voice is flat and even, revealing few signs of emotion. In contrast, Ackelsberg, in blue jeans and rumpled green jacket, necktie askew, speaks in sonorous tones, a hint of the actor he once aspired to be.

Their paths to medicine could hardly have been more dissimilar. Holtz’s was all Iowa. He grew up there and went to college and medical school at the University of Iowa. For Ackelsberg, at age 50—12 years older than Holtz—medical training came much later. “I had been a typical 60s kid who had gone to a number of schools in a number of places,” he said. Before completing Tufts Medical School in 1993, he had variously been an actor, a carpenter, and for 10 years in San Francisco a cab driver. Both men went on to train in public health, and both served for 2 years with the CDC’s Epidemic Intelligence Service before coming to New York City. Now, the two would work in tandem, medical sleuths in search of the source of Kathy Nguyen’s anthrax.

On Monday morning, when Holtz first heard about the suspicion that there was a new inhalation anthrax case, he thought, “Nah, that can’t be possible.” Like others in the department, he thought New York’s seven cutaneous cases were all they would be seeing. Later that day, the department learned that the new case had been confirmed. Holtz recalled his feelings:

Marci Layton asked me to get involved and be sort of the head of the epidemiology investigation at the patient’s workplace, and I thought, “Okay, here we go again.” It’s like it’s not over. It was one thing to have cutaneous cases, but when you have an inhalation case, well we were all extremely worried about what was going to happen that week, that this was a harbinger of worse things to come.

 

Under Layton’s overall coordination, Ackelsberg and Holtz became “sort of the two team leaders,” in Holtz’s words. After their first visit together to Lenox Hill they divided responsibilities. Ackelsberg: “I was focusing more on interviewing friends, seeing her apartment, trying to learn about her and her activities.” Holtz: “I was the one who mainly spoke to her co-workers, people at the hospital she worked at.”

Holtz recalled that when investigators met to interview workers at the Eye and Ear Hospital, agents from the Federal Bureau of Investigation were reluctant to enter the building. They were concerned that it was contaminated, though the health department staff felt the risk was minimal. “In the end, there were two FBI agents who agreed to go inside with us. The rest of them stayed across the street in a hotel and did some interviews over there,” said Holtz.

One of the people that Ackelsberg interviewed was Anna Rodriguez. Weeks after Kathy’s death, Anna was still stunned. She had known Kathy since the early 1980s when Kathy moved to the newly renovated Bronx apartment building. “A classy lady,” Anna said about Kathy, “always neatly dressed.” And her apartment? “It was so clean you could eat off the floor.” Kathy’s monthly rent, which she paid by postal money order, was $675. The building was a Section 8 apartment house, which meant that her rent was 30 percent of her gross income. (“Section 8” refers to a federal program that provides housing subsidies for low-income families.) Kathy’s annual income was about $27,000.

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