The Hot Zone

  “What happened in Zaire?” I asked.

  “When we got to Kinshasa, the place was an absolute madhouse,” he said. “There was no news coming out of Bumba, no radio contact. We knew it was bad in there, and we knew we were dealing with something new. We didn’t know if the virus could be spread by droplets in the air, somewhat like influenza. If Ebola had spread easily through the air, the world would be a very different place today.”

  “How so?”

  “There would be a lot fewer of us. It would have been exceedingly difficult to contain that virus if it had had any major respiratory component. I did figure that if Ebola was the Andromeda strain—incredibly lethal and spread by droplet infection—there wasn’t going to be any safe place in the world anyway. It was better to be working at the epicenter than to get the infection at the London opera.”

  “Are you worried about a species-threatening event?”

  He stared at me. “What the hell do you mean by that?”

  “I mean a virus that wipes us out.”

  “Well, I think it could happen. Certainly it hasn’t happened yet. I’m not worried. More likely it would be a virus that reduces us by some percentage. By thirty percent. By ninety percent.”

  “Nine out of ten humans killed? And you’re not bothered.”

  A look of mysterious thoughtfulness crossed his face. “A virus can be useful to a species by thinning it out,” he said.

  A scream cut the air. It sounded nonhuman.

  He took his eyes off the water and looked around. “Hear that pheasant? That’s what I like about the Bighorn River,” he said.

  “Do you find viruses beautiful?”

  “Oh, yeah,” he said softly. “Isn’t it true that if you stare into the eyes of a cobra, the fear has another side to it? The fear is lessened as you begin to see the essence of the beauty. Looking at Ebola under an electron microscope is like looking at a gorgeously wrought ice castle. The thing is so cold. So totally pure.” He laid a perfect cast on the water, and eddies took the fly down.

  Karl Johnson became the chief of an international WHO team that gathered in Kinshasa to try to stop the Ebola outbreak.

  The other C.D.C. doctor, Joel Breman, who had flown with Johnson to Zaire, became a member of a field exploration team that boarded an aircraft bound for the interior to see what was going on in Bumba. The airplane was a C-130 Buffalo troop-transport, an American-made military aircraft that belonged to the Zairean Air Force. It happened to be President Mobutu’s private plane, equipped with leopard-skin seats, folding beds, and a wet bar, a sort of flying presidential palace that ordinarily took the president and his family on vacations to Switzerland, but now it carried the WHO team into the hot zone, following the Congo River north by east. They sat on the leopard-skin seats and stared out the windows at endless tracts of rain forest and brown river, a featureless blanket broken by the occasional gleam of an oxbow lake or a cluster of round huts strung like beads on a barely visible road or footpath. As he leaned against the window and watched the terrain unfold into the heart of Africa, Breman became terrified of coming to earth. It was safe in the air, high above the immeasurable forest, but down there … It began to dawn on him that he was going to Bumba to die. He had recently been assigned to Michigan as a state epidemiologist, and suddenly he had been called to Africa. He had left his wife back home in Michigan with their two children, and he began to suspect that he would never see them again. He had brought an overnight bag with a toothbrush, and he had managed to pack a few paper surgical masks and some gowns and rubber gloves into the bag. He did not have proper equipment for handling a hot agent. The Buffalo descended, and the town of Bumba appeared, a rotting tropical port spread out along the Congo River.

  The Buffalo landed at an airstrip outside the town. The plane’s Zairean crew was terrified, afraid to breathe the air, and they left the propellers idling while they shoved the doctors down the gangway and heaved their bags out after them. The doctors found themselves standing in the backwash of the Buffalo as it accelerated to take off.

  In the town, they met with the governor of Bumba Zone. He was a local politician, quite distraught. He had found himself in deep waters, in over his head. “We are in a bad way,” he told the doctors. “We have not been able to get salt or sugar.” His voice trembled on the edge of weeping as he added, “We have not even been able to get beer.”

  A Belgian doctor on the team knew how to handle this situation. With a dramatic flourish, he placed a black airline pilot’s bag on the table. Then he turned the bag upside down, and wads of currency slapped out, making an impressive heap. “Governor, perhaps this will make things a little better,” he said.

  “What are you doing?” Breman said to the Belgian.

  The Belgian shrugged and replied in a low voice, “Look, this is the way things are done here.”

  The governor scooped up the money and pledged his full co-operation together with all the extensive resources of government at his disposal—and he loaned them two Land Rovers.

  They pushed north toward the Ebola River.

  It was the rainy season, and the “road” was a string of mudholes cut by running streams. Engines howling, wheels spinning, they proceeded through the forest at the pace of a walk, in continual rain and oppressive heat. Occasionally they came to villages, and at each village they encountered a roadblock of fallen trees. Having had centuries of experience with the smallpox virus, the village elders had instituted their own methods for controlling the virus, according to their received wisdom, which was to cut their villages off from the world, to protect their people from a raging plague. It was reverse quarantine, an ancient practice in Africa, where a village bars itself from strangers during a time of disease, and drives away outsiders who appear.

  “Who are you? What are you doing?” they shouted to the Land Rovers from behind a barrier of trees.

  “We are doctors! We are coming to help!”

  Eventually the people would clear away the trees, and the team would proceed deeper into the forest. In a long and desperate day of travel, they penetrated fifty miles away from the Congo River, and finally, toward evening, they came to a row of round, thatched African houses. Beyond the houses stood a white church in the middle of the forest. Around the church, there were two soccer fields, and in the middle of one field they noticed a heap of burned mattresses. Two hundred yards farther on, they came to the Yambuku Mission Hospital, a complex of low, whitewashed buildings made of concrete, with corrugated tin roofs.

  The place was as silent as a tomb and appeared to be deserted. The beds were iron or wooden frames without mattresses—the blood-soaked mattresses had been burned in the soccer field—and the floors were clean, spotless, rinsed. The team discovered three surviving nuns and one priest, along with a few devoted African nurses. They had cleaned up the mess after the virus had wiped out everyone else, and now they were busy fogging the rooms with insecticide, in the hope that it might somehow disperse the virus. One room in the hospital had not been cleaned up. No one, not even the nuns, had had the courage to enter the obstetric ward. When Joel Breman and the team went in, they found basins of foul water standing among discarded, bloodstained syringes. The room had been abandoned in the middle of childbirths, where dying mothers had aborted fetuses infected with Ebola. The team had discovered the red chamber of the virus queen at the end of the earth, where the life form had amplified through mothers and their unborn children.

  The rains continued all day and night. Around the hospital and the church stood the beautiful ferocious trees, a complex of camphors and teaks. Their crowns entwined and crisscrossed and whispered with rain, and bowed and shifted as troops of monkeys passed through them like currents of wind, leaping from crown to crown, crying their untranslatable cries. The next day, the doctors set out deeper into the forest in their Land Rovers, and they made contact with infected villages, where they found people dying in huts. Some of the victims had been put into isolation huts on the edge of th
e village—an old African technique for dealing with smallpox. Some of the huts where people had died had been burned down. Already the virus seemed to be petering out, and most of the people who were going to die were already dead, the virus having echoed so swiftly through Bumba. A wave of emotion rolled over Joel Breman as he realized, with the clarity of a doctor who suddenly sees into the heart of things, that the victims had received the infection from the hospital. The virus had taken root with the nuns and had done its work among those who had sought help from them. In one village, he examined a man dying of Ebola. The man sat in a chair, holding his stomach and leaning forward with pain, and blood streamed around his teeth.

  They tried to reach Kinshasa by radio, to tell Karl Johnson and the others that the epidemic had already peaked. A week later, they were still trying to make radio contact, but they could not get through. They traveled back to the town of Bumba and waited by the river. One, day an airplane droned overhead. It circled the town once and touched down, and they ran for it.

  At the Ngaliema Hospital in Kinshasa, Nurse Mayinga had been put into a private room, which was accessible through a kind of entry room, a gray zone, where the nurses and staff were supposed to put on bioprotective gear before they entered. Mayinga was cared for by a South African doctor named Margaretha Isaäcson, who at first wore a military gas mask, but it became increasingly uncomfortable in the tropical heat. She thought to herself, I can’t bear it, I’ll be surprised if I come out of this alive anyway. That made her think about her own children. She thought, My children are grown up, they are no great responsibility. And she removed her mask and treated the dying girl face-to-face.

  Dr. Isaäcson did everything she could to save Mayinga, but she was as helpless before the agent as medieval doctors had been in the face of the black plague. (“This was not like AIDS,” she later recalled to me. “AIDS is child’s play compared with this.”) She gave Nurse Mayinga ice cubes to suck on, which helped to ease the pain in her throat, and she gave her Valium to try to stave off her apprehension of what lay ahead.

  “I know I am dying,” Mayinga said to her.

  “That’s nonsense. You are not going to die,” Dr. Isaäcson replied.

  When Mayinga’s bleeding began, it came from her mouth and nose. It never came in a rush, but the blood dripped and ran and would not stop and would not clot. It was a hemorrhagic nosebleed, the kind that does not stop until the heart stops beating. Eventually Dr. Isaäcson gave her three transfusions of whole blood to replace what she lost in nosebleeds. Mayinga remained conscious and despondent until the end. In the final stage, her heart developed a galloping beat. Ebola had entered her heart. Mayinga could feel her heart going blubbery inside her chest as Ebola worked its way through her heart, and it frightened her unspeakably. That night, she died of a heart attack.

  Her room was contaminated with blood, and there was also the question of the two nuns’ rooms, both of which were still locked and bloodstained. Dr. Isaäcson said to the staff, “I won’t be of much use to you now,” and she got a bucket and mop and washed the rooms.

  Medical teams fanned out into Kinshasa and managed to locate thirty-seven people who had had face-to-face contact with Mayinga during the time when she had wandered around the city. They set up two biocontainment pavilions at the hospital and shut the people up for a couple of weeks. They wrapped the cadavers of the nuns and Nurse Mayinga in sheets soaked in chemicals, then double-bagged the mummies in plastic and put each one in an airtight coffin with a screw-down lid, and held the funeral services at the hospital, under the watch of doctors.

  Karl Johnson, having heard nothing from the team of doctors upriver in Bumba, wondered if they were dead, and assumed that the virus was about to go on a burn through the city. He organized a floating hospital ship and had it moored in the Congo River. It was an isolation ship for doctors. The city would be the hot zone, and the floating ship would be the gray area, the place of refuge for the doctors. Approximately a thousand Americans were living in Zaire at the time. In the United States, the Army’s Eighty-second Airborne Division went on alert and prepared to evacuate the Americans by air as soon as the first Ebola cases started popping up in the city. But to the strange and wonderful relief of Zaire and the world, the virus never went on a burn through the city. It subsided on the headwaters of the Ebola River and went back to its hiding place in the forest. The Ebola agent seemed not to be contagious in face-to-face contacts. It did not seem to be able to travel through the air. No one caught the virus from Nurse Mayinga, even though she had been in close contact with at least thirty-seven people. She had shared a bottle of soda pop with someone, and not even that person became ill. The crisis passed.

  CARDINAL

  1987 SEPTEMBER

  As with Ebola, the secret hiding place of the Marburg agent was unknown. After erupting in Charles Monet and Dr. Shem Musoke, Marburg dropped out of sight, and no one could say where it had gone. It seemed to vanish off the face of the earth, but viruses never go away, they only hide, and Marburg continued to cycle in some reservoir of animals or insects in Africa.

  On the second day of September 1987, around suppertime, Eugene Johnson, the civilian biohazard expert attached to USAMRIID, stood in a passenger-arrival area outside the customs gates at Dulles International Airport, near Washington. He was waiting for a KLM flight from Amsterdam, which carried a passenger who had come from Kenya. A man with a duffle bag passed through customs, and he and Johnson nodded to each other. (“I’m going to leave this person’s name out of it. Let’s just say he was someone I knew, someone I trust,” Johnson explained to me.) The man laid down the duffle bag at Johnson’s feet, unzipped it, and pulled out a wad of bath towels wrapped around something. Pulling off the towels, he revealed an unmarked cardboard box wound with tape. He handed the box to Johnson. They had little to say to each other. Johnson carried the box out of the terminal building, put it in the trunk of his car, and drove to the Institute. The box held blood serum from a ten-year-old Danish boy who will be called Peter Cardinal. He had died a day or so earlier at Nairobi Hospital with a combination of extreme symptoms that suggested an unidentified Level 4 virus.

  As he drove to the Institute, Johnson wondered just what he was going to do with the box. He was inclined to sterilize its contents in an oven and then incinerate it. Just cook it and burn it, and forget it. Most of the samples that came into the Institute—and samples of blood and tissue arrived constantly from all parts of the world—contained nothing unusual, no interesting viruses. In other words, most of the samples were false alarms. Johnson wasn’t sure he wanted to take the time to analyze this boy’s blood serum, if, in all probability, nothing would be found in it. By the time he pulled into the gates of Fort Detrick, he had decided to go ahead. He knew the work would keep him up most of the night, but it had to be done immediately, before the blood serum deteriorated.

  Johnson put on a surgical scrub suit and rubber gloves, and carried the box into the Level 3 staging area of the Ebola suite, where he opened the box, revealing a mass of foam peanuts. Out of the peanuts he fished a metal cylinder sealed with tape and marked with a biohazard symbol. Along the wall of the staging area was a row of stainless-steel cabinets with rubber gloves protruding into them. They were Biosafety Level 4 cabinets. They could be sealed off from the outside world while you handled a hot agent inside them with the rubber gloves. These cabinets were similar in design to the safety cabinets that are used for handling nuclear-bomb parts. Here the cabinets were designed to keep human beings from coming into direct contact with Nature. Johnson unscrewed some wingnuts and opened a door in the cabinets, and placed the metal cylinder inside. He closed and tightened the door.

  Next, he put his hands into the gloves, picked up the cylinder and, looking through a window to see what he was doing, peeled the tape off the cylinder. The tape stuck to his rubber gloves, and he couldn’t get it off. Damn! he swore to himself. It was now eight o’clock at night, and he would never get home. Finally he
got the cylinder open. Inside it was a wad of paper towels soaked in bleach. He pulled apart the wad and found a Ziploc bag. It contained a couple of plastic tubes with screw tops. He unscrewed them and shook out two very small plastic vials containing golden liquid: Peter Cardinal’s blood serum.

  The boy’s mother and father worked for a Danish relief organization in Kenya, and lived in a house in the town of Kisumu, on Lake Victoria. Peter had been a student at a boarding school in Denmark. That August, a few weeks before he died, he had gone to Africa to visit his parents and his older sister. She was a student at a private school in Nairobi. She and Peter were very close, and while Peter was visiting his family in Kenya, the two young people spent most of their time together—brother and sister, best friends.

  The Cardinal family went on vacation after Peter’s arrival, and traveled by car through Kenya—his mother and father wanted to show him the beauty and sweetness of Africa. They were visiting Mombasa, staying in a hotel by the sea, when Peter developed red eyes. His parents took him to the hospital, where the doctors examined him and concluded that he had come down with malaria. His mother did not believe it was malaria. She began to perceive that her son was dying, and she became frantic. She insisted that he be taken to Nairobi for treatment. The Flying Doctors, an air-ambulance service, picked him up, and he was flown to Nairobi and rushed to Nairobi Hospital, where he came under the care of Dr. David Silverstein, who had also taken care of Dr. Musoke after Charles Monet had spewed the black vomit into Musoke’s eyes.

  “Peter Cardinal was a blond-haired, blue-eyed guy, a tall, thin guy, a fit-looking ten-year-old,” Dr. Silverstein recalled as we drank coffee and tea at a table in the shopping mall near his house outside Washington. A small girl sitting nearby burst into wails, and her mother hushed her. Crowds of shoppers passed by our table. I kept my eyes on Dr. Silverstein’s face—steel-rimmed glasses, mustache, eyes that gazed into space—as he recalled the unusual death he had seen, which he spoke of in a matter-of-fact way. “When Peter came to me, he was febrile, but he was very with it, very alert and communicative. We gave him an X ray. His lungs were fluffy.” A kind of watery mucus had begun to collect in the boy’s lungs, which caused him difficulty in breathing. “It was a typical ARDS picture—acute respiratory distress syndrome—like early pneumonia,” Dr. Silverstein said. “Shortly afterward, he started turning bluish on me. He had blue in his fingertips. Also, he had little red spots. I had everybody glove up before they handled him. We suspected he had Marburg, but we didn’t have the paranoia we had had with Dr. Musoke. We just took precautions. In twenty-four hours, he was on a respirator. We noted that he bled easily from puncture sites, and he had deranged liver functions. The small red spots became large, spontaneous bruises. He turned black-and-blue. Then his pupils dilated up on us. That was a sign of brain death. He was bleeding around the brain.”