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Authors: Laurie Garrett

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He left Yambuku having recommended that the Sisters take three measures immediately: “(1) Hospitalize the cases. (2) Use public cemeteries.
5
(3) Boil potable water.”
What Ngoi had written, though he did not know it at the time, was the first historic description of a new disease. In clear, succinct, and, as time would show, largely accurate terms, Ngoi had described what would prove to be the second most lethal disease of the twentieth century.
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At five o'clock in the afternoon of September 19, Sister Béata died. The same day reports came into the mission of illnesses and deaths from the bizarre bleeding disease in over forty villages. By now, there was real danger of a mass exodus of hysterical villagers fleeing to nearby zones—and taking the disease with them. Through the missionary radio relay system, the Sisters sent more urgent pleas for assistance.
Federal authorities dispatched two professors from the National University of Zaire to Yambuku: microbiologist Muyembe Tamfum Lintak and epidemiologist Omombo. They reached the mission on September 23, intending to conduct a six-day study of the problem, but cut their visit short and beat a hasty retreat from Yambuku after just twenty-four hours.
When they arrived at Yambuku Hospital, Muyembe and Omombo saw despair and horror everywhere they turned. Just hours before they arrived, twenty-six-year-old mission nurse Amane Ehumba had died of the disease, and anxieties among the Zairian hospital employees were at near-panic levels.
The professors first focused on a small child who was writhing in agony in a hospital crib. While they discussed what might be done, the child died before their eyes. The academics were shaken from their intellectualizing, and immediately set to work collecting blood and tissue samples from patients and cadavers, interviewing ailing patients and reviewing their medical charts.
As the professors commenced their research, Sister Myriam, who had nursed Sister Béata, was suddenly overcome by piercing headaches and fever. The fear among the mission staff was contagious.
Unfortunately, the academics hadn't taken Ngoi's field report seriously, and brought no protective gloves, masks, or gowns for their use during procedures that put them in contact with infected blood. Still, they worked around the clock, examining five blood samples for signs of malaria, parasites, or bacteria. They found nothing. When they performed autopsies, Muyembe and Omombo were aghast at the extensive damage inflicted by the disease, and removed liver samples to send to sophisticated laboratories for further analysis.
Sister Romana arrived during the day, having traveled all morning from the Lisala Mission, located in the zone to the southwest of Bumba. “I have come,” she told the other Belgians, “to replace Sister Béata.” The visiting nun set to work immediately, looking after the latest victims.
Among them was Sophie, still severely ill at that point, groaning in agony in her hospital bed. While the professors inspected the wards, their guide, nurse Sukato Manzomba, progressed from being mildly feverish to a life-threatening state. She began vomiting blood and passed into delirium. The stunned professors acceded to the missionaries' pleas and agreed to take Sister Myriam, Father Augustin (who had traveled with Antoine in northern Zaire and was running a high fever), and Sister Edmonda (as an accompanying nurse) back to Kinshasa for treatment.
The group traveled the muddy, bumpy road from Yambuku to Bumba in a Land-Rover, passing several villages along the way, and were airlifted the following day to Kinshasa aboard a Zairian Air Force transport jet. Left to their own devices at Kinshasa's N'djili Airport, inexplicably abandoned by the professors, the missionaries were forced to take a taxi to Ngaliema Hospital—Zaire's premier teaching facility.
From the moment she arrived it was obvious to the Ngaliema staff that Sister Myriam needed not a hospital bed, but a deathbed.
Because they had no idea what pathogen was producing the Sister's illness, the Ngaliema staff didn't know what precautions they should take. Sister Edmonda described the rapid spread of the disease inside Yambuku Hospital and volunteered to do the bulk of Sister Myriam's care. The ailing nun was placed in an isolated ward. A pretty young student nurse, Mayinga N'Seka, offered her assistance and Dr. Lusakumuna took charge of the case. Collectively they did what they could to ease Sister Myriam's suffering.
On September 30, despite their efforts, Sister Myriam died in the Kinshasa hospital.
Dr. William Close was in Wyoming at the time, negotiating the purchase of a ranch. For sixteen years he had lived in Kinshasa, serving as personal physician to President Mobutu Sese Seko and directing a nongovernmental medical development group called Cooperation Médicale Belge. The American physician and his family
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had arrived in Zaire when Mobutu seemed a heroic, towering figure on the African landscape, a leader of postcolonial black Africa, and an inspiration to young idealists worldwide. But over the years Close witnessed Mobutu's transformation from a sort of Zairian George Washington to a tyrannical and corrupt despot enamored of the works of Machiavelli and surrounded by family and associates who treated Zaire's national bank as their personal cash register.
Grown cynical, Close was preparing for a new life in Wyoming when Dr. Ngwété Kikhela, Zaire's Minister of Health, called to ask Close to notify American authorities, requesting assistance. Close immediately contacted the Centers for Disease Control in Atlanta, apprising the agency of the situation and formally requesting laboratory support to determine the cause of the Yambuku outbreak.
Back at the mission, more of the hospital staff contracted the disease. Now ten of the seventeen employees were either dead or too sick to continue tending to patients. Following Muyembe's parting recommendations, Sister Genoveva closed the hospital to all but the remaining dying victims of the mysterious disease. Though she had no medical training and was one of the mission's teaching nuns, Sister Genoveva was forced to carry the onus: none of the Belgian medical personnel remained well enough to shoulder such responsibilities.
Sister Romana lay in one bed, vomiting blood, bleeding from her gums, suffering acute diarrhea, and groaning in delirium. The elderly Father Germain Lootens was similarly stricken, and none of the remaining Zairian nurses felt up to staffing the hospital without their supervision.
Lacking medical skills, Sisters Genoveva, Marcella, and Mariette turned to the only weapon in their armamentarium: prayer. For hours on end the grief-stricken nuns and the three remaining priests prayed over the sickbeds of their friends and colleagues, hoping their devout entreaties would bring a miracle.
Despite their prayers, Sister Romana died at noon on October 2. Word of her death, radioed by the Yambuku staff to the Lisala Mission, produced both tremendous grief and justifiable fear among her old friends. Just six hours later, Father Lootens also passed away and this threw the surviving Belgian missionaries into such despair and terror that a visiting team of Kinshasa scientists found the group virtually paralyzed by anxiety.
At Minister Ngwété's request, a team of medical experts had been assembled and flown to Bumba by the Zairian Air Force. From there they drove to Yambuku. The three-man team arrived shortly after the deaths of Sister Romana and Father Lootens. Ministry officials, notified of the deaths by relayed radio messages, ordered the area placed under strict quarantine and “cordons sanitaires” established around Yambuku.
Having no experience in such matters, Sister Genoveva took the order literally. She gathered up rolls of bandage gauze and strung them around the periphery of the mission and suspended signs from the “cordons” warning visitors to stay away. A large bell was hung at the mission entry, with a sign telling visitors to ring, leave their messages or food donations, and quickly withdraw.
Close explained the crisis to President Mobutu, who expressed concern about containing the epidemic, and put his personal Hercules C-130 transport jet at the disposal of the medical effort. He also ordered the entire Bumba Zone placed under strict isolation. All roadways, waterways, and
airfields in the region were placed under martial law, and the transport of goods and people in and out of the area came to a full stop within a week. The village elders of the Bumba Zone, recalling the smallpox epidemic of the 1960s, advised their people to remain housebound until the epidemic passed. Overnight all commerce, social life, schooling, and ritual gatherings ceased and the villages surrounding Yambuku looked like ghost towns.
Close helped gather medical supplies, rudimentary lab equipment, and other hospital essentials from warehouses and hospitals around Kinshasa, and these were loaded aboard Mobutu's jet and flown to Bumba.
Meanwhile, the three-man team of Kinshasa-based investigators, composed of Zairian health official Dr. Krubwa, Belgian medical mission director Dr. Jean-François Ruppol, and French medical mission chief Dr. Gilbert Raffier, did their best to comfort the extremely upset Yambuku missionaries. They gathered more blood and tissue samples, examined medical records, and toured local villages. Though the scientists still had little solace to offer, the missionaries were greatly relieved, and radioed gratitude to Bumba for the supplies and physicians.
At about the same time, Paul Brès received word that another strange epidemic was unfolding in a town called Maridi in the grasslands of southern Sudan. Information was scarce, and authorities in the Sudanese capital of Khartoum had no radio contact with that impoverished and distant region to the south. Still, Brès and other experts in the virus branch of WHO thought—from their distant Geneva vantage point—that the Sudanese accounts bore a remarkable resemblance to those from Yambuku. He urged Khartoum to immediately send blood and tissue samples from Maridi patients.
But it was no simple matter for a doctor in Khartoum to make his way to Sudan's southernmost provinces, gather blood samples, store the precious fluids in containers that would protect their contents from the intense desert heat, and make his way back to Khartoum. In addition to the usual—and monumental—logistic obstacles to such a trek, whoever went faced the even more towering blockade of politics.
But the mysterious epidemic was occurring in one of the country's three most southerly provinces, where the people lived and believed as they had since before the Nubians were enslaved by Egypt's Pharaohs. Speaking a variety of ancient Bantu languages, the southern Sudanese were animists who believed all living things, as well as the sun, water, wind, and weather, had a spiritual character. The manipulation of these often unpredictable and fickle spirits and gods was the province of fate: wise sorcerers knew how best to cajole the spirits to support their ends or repel evil spirits that produced illness, death, and misfortune. The southerners lived in small, temporary villages, were often nomadic, had a high rate of illiteracy, and could not be expected to be found in any particular locale at any specific time.
In 1969 Sudan had a military coup d'état. A Muslim-led civilian government backed by the military was installed, and the nation teetered on the edge of civil war, splitting the Muslim north and the Christian, animist south until 1972. Then a semblance of peace took hold when a constitutional agreement was reached, providing the three southern provinces with a fair degree of self-rule. The autonomous region was only nominally connected to the Khartoum-based infrastructure, and it was rare indeed that a Ministry of Health official from the north would be asked, or would agree, to intercede in medical problems to the south.
Still, Brès and other Geneva officials insisted on pushing past the political obstacles to discover what was going on in Maridi. Their greatest fear was that the epidemics of Yambuku and Maridi were one and the same, representing a vast super-lethal disaster spanning an area of about 1,000 square miles in at least two nations.
Blood samples, collected in Maridi and shipped over several days' time to Khartoum, finally reached Geneva. They were in poor condition, but WHO immediately sent them on for analysis in laboratories in the United States and the U.K.
8
WHO enlisted high-security laboratories all over the world in the effort. It wasn't hard, really: everybody wanted a piece of the action. Though the best guess was that the disease was caused by the yellow fever virus, the outbreaks were something new, intellectually exciting. Throughout October and November blood and tissue samples from disease victims in Yambuku, Kinshasa, and Sudan were sent to laboratories in the United States (Centers for Disease Control, Atlanta), the U.K. (the Microbiological Research Establishment, Porton Down, Salisbury), Belgium (the University of Anvers and the Prince Leopold Institute of Tropical Medicine), West Germany (Bernard Nocht Institute for Naval and Tropical Diseases), and France (special pathogens branch of the Pasteur Institute).
On October 11 the Pasteur Institute's director of overseas research, Claude Hannon, told Pierre Sureau to go to Roissy Airport to retrieve a package containing blood samples from Kinshasa, adding that he should “consider the packet's contents dangerous.” The perilous shipment was, however, misrouted to Paris's Percy Hospital, passing through many hands before Sureau was able to track it down.
When hours later he obtained the curious box and opened it at his lab bench, Sureau found a thermos flask containing several Vacutainer tubes of blood surrounded by dry ice—a commonly used freezing protective layer. Tucked among the tubes was a note from Dr. G. Raffier of the French Embassy in Kinshasa, dated October 10, 1976:
Sir, the enclosed tubes contain blood samples collected at a mission October 4 to 9 on patients and illness contacts at the hospital of the Catholic Mission of Yambuku, Bumba Zone, Equatorial Region of the Republic of Zaire. This village of Yambuku and another close neighbor, Yandongi, are currently seized by a deadly epidemic of indeterminant nature. It began September 5. It is now in regression (10-9-76) … . The first assumptions were that the region was hit by yellow fever
(but four of the dead Belgian missionaries were vaccinated) or typhoid fever. The first analysis done at the Institute of Tropical Medicine (IMT) of Anvers eliminated yellow fever and typhoid; a virus not seen before was isolated at Anvers.
9
We have not yet received results of a liver biopsy sent to Dakar. A diagnostic assumption of Lassa has been advanced, but not proven to date. The fresh blood samples have been preserved on dry ice.
10
 
Sureau knew Lassa could be terribly dangerous—he'd certainly heard of Jordi Casals's near-fatal infection. But he had no reason to believe the suspected virus could be airborne. He placed the nine tubes in a rack atop a sterile lab table, opened the first, and dabbed a sample on filter paper.
The implications of such casual behavior would be obvious a few weeks later. One of the tubes contained Sister Edmonda's blood.
But as Sureau looked at the tubes his only thought was: “What shall I do first? Electron microscopy? Antibody complementarity assays?”
He was smoking a cigarette, mulling it over, when the phone rang. Paul Brès, chief of the Viral Diseases Branch of WHO, was calling from Geneva.
“Pierre, have you received the suspected blood samples from Zaire?” he asked.
“Yes, Paul, I got them this morning.”
In an urgent tone Bres stressed that the samples were “highly infectious and must be studied in a maximum-security laboratory. They must be sent on immediately to the CDC in Atlanta. Don't open them!”
“Too late, Paul, I already did,” Sureau said, anxiously glancing at the nine neatly lined-up tubes.
Brès instructed Sureau to repackage the tubes immediately and ship them by overnight plane to Atlanta. Then Bres asked Sureau whether he would serve as the official WHO consultant for the mysterious epidemic. Sureau agreed without hesitation and left the following day for a briefing in Geneva. He would be in Kinshasa within thirty-six hours.
As requested, Sureau sent the nine test tubes to Karl Johnson at the CDC, and enclosed his own note summarizing the contents of Raffier's letter and information from Paul Brès, noting that he had repacked the samples in more secure containers.
“I am leaving this evening for Kinshasa on a mission for WHO,” Sureau concluded, “to participate on the ground in research. My instructions are to send to the CDC clinical samples I collect.”
A week earlier, Peter Piot, then only twenty-seven years old, was completing his virology postdoctoral research at Anvers when the first mysterious
blood samples had arrived from Zaire. With Piot were Flemish biochemist Guido van der Gröen, Bolivian physician René Delgadillo, and their boss, Stefan Pattyn. The group looked at the odd blue thermos that reached them via Brazzaville and discussed rumors they'd read about in the Dutch press of, as van der Gröen put it, “something weird in Zaire, involving Belgian missionaries.”
An accompanying note from WHO authorities in Brazzaville indicated that yellow fever was suspected.
“Well, that's not very dangerous. Not in the lab anyway,” Piot reasoned. He blithely pulled on a pair of latex gloves and, without further precautions, opened the thermos. Inside he found a soup of melted ice, an illegible, water-soaked note from somebody in Zaire, an intact test tube, and another one, broken into pieces, its contents mixed into the watery soup. Piot, under the watchful eyes of his colleagues, removed the intact tube, setting it out on the tabletop in their lab inside a mundane research facility in the city of Antwerp.
Years later, while eating a luncheon salad of
jambon
and
fromage
in a noisy Rive Gauche café in Paris, Piot would explain that he had been “young, foolish, and fearless” and that it wasn't until well after Christmas in 1976 that he stopped to reflect on the tremendous dangers he had faced. Only then did he allow himself to finally experience fear.
But in the first week of October all the ambitious young Belgian saw when he looked at the samples was a wondrous mystery. He and van der Gröen first prepared samples for standard yellow fever antibody tests, using antibodies that would react with the contents if the virus was present. Negative. He repeated the yellow fever test. Still negative. Then he tried typhoid antibody. Also negative.
But van der Gröen confirmed that whatever was in that odd blue thermos from Zaire was quite deadly by putting droplets from the intact test tube into larger tubes containing so-called Vero monkey cells. Within eleven days, the Vero cells were dead, and when van der Gröen withdrew liquid from the dead Vero tubes and put it in tubes full of fresh Vero cells, they too died within ten to eleven days.
The laboratory in which this work was done had no special security or containment facilities, no fancy hoods to draw dangerous bugs up into ducts, away from scientists' mouths. Indeed, the Belgians labored under conditions no more sophisticated or secure than might be found in a typical high school biology lab.
Their folly would prove striking in retrospect, and all concerned would later express astonishment that they suffered no ill consequences from such frivolous disregard of the potential hazards of the microbes.
Indeed, three days into their research, the much older Pattyn removed a rack full of incubating infected Vero cells for examination. He tilted the rack to get a clearer look, and a tube slid out, crashing to the laboratory floor.
Delgadillo and van der Gröen stared in panic at the wet floor, the Bolivian noting that liquid had splashed on his shoes. Van der Gröen, spotting his Bolivian colleague's anxious glances at his shoes, looked at his feet as well: fluid splattered his wing tips in deadly little beads. Delgadillo and van der Gröen exchanged worried glances.
After a few moments, Pattyn suggested that van der Gröen “clean it up,” and left the laboratory. With gloved hands, van der Gröen and Delgadillo gingerly wiped up the floor and their shoes, then liberally spread disinfectant around the facility.
Shortly after the Belgian group's Vero cell studies confirmed the dangers of the mysterious Zairian microbes, their government began questioning the wisdom of continuing the Antwerp research effort. They were instructed to pass the samples on to higher-security laboratories outside Belgium. Van der Gröen convinced Pattyn to save one small sample, reasoning that it should be used as a backup, in case the primary samples were damaged or lost in shipment to Porton Down.
Having ruled out the easy answers, Piot eagerly prepared the sample for analysis under an electron microscope. He gasped as he stared at the strange viruses; they were shaped like question marks.
“This is a new virus! It's something we have never seen before,” he exclaimed, feeling the thrill of discovery. The virus was a long wormlike tube that coiled at one end and left the other extended. Piot imagined that when he asked, “What is this?” the viruses simply answered back: “????”
Thoroughly committed to solving the mystery of the “???? viruses,” Piot was disappointed when WHO telexed on October 7 that the group should cease all research immediately, saying, “Investigations indicate this may be Marburg.” Piot packed the last sample, wrote up his findings, and, as per WHO instructions, shipped the lot off to Karl Johnson at CDC. He was intrigued by the diagnosis and wanted to go to the scene of the epidemic to see for himself.
The usually shy Piot uncharacteristically marched over to the Belgian Ministry of Development Cooperation and argued his case. “We have to be there,” he said. “There are missionaries, Belgian missionaries who died.”
He didn't need to underscore Belgium's unique relationship with Zaire. In 1876 the European power had begun to colonize and brutalize the Congo, as it was called. Now, almost exactly a hundred years since King Leopold II declared the Congo a part of the Belgian Empire, authorities in Brussels were at pains to rid their country of its guilty legacy. On the other hand, the Belgian government was also acutely aware of the risks inherent in offending Mobutu or his government. It was an extremely delicate situation to place in the hands of a twenty-seven-year-old, politically naïve postdoctoral student.
“All right,” Piot was told, “You can go. We will only fund one week. And you're representing the Belgian government.”
Carrying the only suit he owned, he may have been prepared to meet officials in Kinshasa and travel around Zaire for a week. But he was woefully ill equipped for what would become a three-month stay in a tropical rain forest during the Zairian summer.
Dr. Stefan Pattyn, before sending his samples on to England's maximum-security laboratory in Porton Down, had completed studies in laboratory mice, which showed that the virus was quite lethal to rodents. He had also compared the mystery virus to Lassa, concluding that “it was probably some other arbovirus,” not the West African killer. Now he too departed for Zaire, leaving van der Gröen behind to monitor the health of the accident-exposed members of the Antwerp laboratory.
On October 14, Patricia Webb and Fred Murphy completed their first round of studies of the mystery virus, working in the CDC's maximum-security laboratory. In 1976 the lab was designated a P3 facility. A P1 facility was a basic laboratory such as could be found lining the hallways of university science departments; a P2 facility had a slightly higher level of security with entry limited to trained, authorized personnel and actual research work performed under hoods that sucked air away from the experiment, up a ventilator duct, and past scrubbers that disinfected the air with ultraviolet light and microscopically gridded filters; a P3 lab was state of the art in high-security research. For Webb, working in a P3 lab meant passing through a series of guarded locked doors, presenting her security pass for entry. She would then shower with disinfectant soap and don a set of head-to-toe protective clothing, gauze face mask, double latex gloves, and radiation badge to monitor her levels of exposure to isotopes occasionally used in such research. She would then pass through two more air locks lined with microbe-killing ultraviolet lights.
Once inside the inner core, Webb might enter either the laboratory or the animal room. Both rooms were pressurized; all air was forced in past microscopic filters and sucked back out rapidly through several additional layers of filters, ultraviolet lights, high heat sources, and chemical scrubbers.
A further layer of protection was provided by glove boxes: more sophisticated versions of the portable box Karl Johnson jury-rigged for his studies of the Machupo virus in Bolivia. All Webb's samples from Zaire were stored in deep freezers overnight; small amounts were thawed during the day and analyzed inside the boxes. Webb would thrust her already double-gloved hands into a larger set of thick rubber gloves that were permanently installed in the clear-plastic front wall of the hooded box. She would then try, with three cumbersome layers of rubber over her hands, to manipulate test tubes, pipettes, petri dishes, and the like. It was slow-going, arduous work that often proved physically exhausting.
Harder still was the animal work. To find a mysterious microbe, it was necessary to inject samples into mice, guinea pigs, hamsters, and monkeys, all of which were also kept in large glove boxes. The animals didn't sit
still in the grasp of bulky gloved hands, and injections were often a test of wills between scientist and guinea pig.

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