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Authors: Laurie Garrett

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In such a setting the greatest risks to the scientists were accidents, such as cutting oneself with a broken contaminated test tube or receiving an animal bite. Webb had never cut herself, but she had been bitten several times by monkeys that attacked her approaching gloved hands. Fortunately, those monkeys were part of Webb's Machupo research, and, having already suffered the disease, she was immune.
These Zairian samples, however, tested negative for Machupo, and Webb was acutely aware of the need to work with slow, cautious deliberation. It was not her style, really. When Patricia Webb graduated in 1950 from Tulane University Medical School in New Orleans, only eight other women were in her class. In those days a handful of women were given the opportunity to matriculate into a field dominated by males. Unlike most of her fellow students, Webb never planned to spend her life in a profitable practice giving middle-class kids antibiotics for strep throat and monitoring the blood pressures of obese patients.
Since childhood in England Webb had been fascinated with stories of India, Pakistan, and China and saw medicine as a sort of universal passport.
It hadn't gotten her to India yet, but through medicine and research virology she had already seen Malaysia, Panama, Bolivia, California, Louisiana, Georgia, and the Washington-Baltimore area. But now she found herself locked inside an artificial environment day after day.
The further Webb got into her research, however, the more obvious it became that the CDC needed to deploy a team immediately for fieldwork on the ground in Yambuku. With the approval of her CDC seniors, Webb began amassing further information and planning her fieldwork.
She asked the CDC's personnel office to find a staff scientist with three key qualifications: fluency in French, strong African experience, and training in epidemiology. The name Joel Breman popped up.
Breman had spent six years in Africa since completing his medical studies—two years in Guinea and four in Burkina Faso. He had been part of D. A. Henderson's successful campaign to eradicate smallpox, and he was fluent in African-dialect French. But Webb was a little anxious when she noted he was technically an EIS (the CDC's Epidemic Intelligence Service) trainee.
In late September, when the CDC's Lyle Conrad contacted Breman in Michigan, the epidemiologist was knee-deep in another investigation—of Swine Flu. Conrad asked if the EIS trainee would like “one hell of an assignment. It's in Africa, it's a little frightening. Something has killed just about every villager in the area. You'd be gone about a week.”
Having spent six years in tropical Africa, Breman knew nothing got done in one week. And he didn't like the sound of this particular mystery. Nevertheless, over the next three weeks the tall, bearded scientist talked
almost daily over the phone with Webb, getting a sense of the excitement and fear surrounding the Zaire outbreak. For her part, Webb soon grew used to Breman's long-winded, often cliché-packed ramblings. Beneath his occasionally incoherent conversational style lay a sharp intellect that Webb recognized and planned to push to its limits in Yambuku.
On October 10, Webb and her co-worker, Fred Murphy, officially informed WHO that “the illness is caused by a virus that resembles Marburg (Marburg-like), that the epidemics are probably caused in Zaire and Sudan by an etiological agent that is similar but represents a new immunotype that is in the family of Marburg.”
11
Webb's Marburg speculation prompted an international escalation in scientific security. Thereafter the CDC and Porton Down—the world's most secure labs in 1976—received virtually all samples of the mystery agent.
At Porton Down it was Geoffrey Platt who handled most of the mystery virus research. His lab wasn't exactly an American-standard P3 facility; rather it was a uniquely English mix of P3 and P2 elements. Because the British antivivisection movement was quite militant in its opposition to the use of laboratory animals, security in the form of controlling access to Porton Down was very high. Indeed, most British citizens had no idea where the lab was located or what it did.
Since 1964 Platt had worked at Porton Down with dangerous viruses, particularly Lassa, taking precautions to protect himself, though the microbes were not kept safely inside glove boxes, as was done at the CDC. The rooms were, indeed, pressurized, and the air was decontaminated before being released into the English countryside, but Platt's personal protection was limited to a cloth surgical gown, a double layer of latex gloves, and an old World War II-era gas mask. Though the respirator had been thoroughly tested for its effectiveness in protecting British soldiers from combat gases, it had never been proven that the mask filtered out viruses. Nevertheless, the handful of Porton Down scientists and technicians who worked with super-lethal microbes were limited to using the cumbersome, often hot masks that always seemed to cloud up in the midst of delicate procedures, usually leaving researchers with headaches by the end of the day.
Every night after work, Platt would scrub his mask with Lysol and spray it with formalin disinfectant.
Though mindful of the risks, and very careful in his work, Platt knew there were dangers, especially when working with an unknown, Marburg-like killer.
“Care is absolutely essential,” Platt told his colleagues, warning that nobody should enter his lab or animal care area unless absolutely necessary—at least, not until Platt knew what lurked in those test tubes. “You've got to realize you're working in some danger and be able to accept that. It's not good if you're going to go home at night and not be able to sleep.”
Platt had no way of knowing that in just three weeks he himself would lose a great deal of sleep worrying about his own chances of survival.
Platt's work on the Sudan samples prompted WHO to release, on October 15, the following urgent bulletin:
 
Haemorrhagic Fever of Viral Origin.
Between July and September 1976, it was observed in the region spanning N'zara to Maridi, in southern Sudan, sporadic cases of fever with haemorrhagic manifestations. It is thought that the first cases occurred among agricultural families. During the last week of September, the situation worsened considerably, 30 of 42 cases occurred in Maridi hospital among members of the staff; it is thought the disease was spread directly from one person to another. By October 9, 137 cases, 59 deaths, were reported for the region comprising N'zara, Maridi and Lirangu. The epidemic has caused panic on the local level … .
 
The report closed with these words: “Samples from Sudan and Zaire have revealed the presence of a new virus, morphologically similar to Marburg, but antigenically different.”
Well before WHO officially released that report, the agency had confirmed from three labs (CDC, Anvers, Porton Down) that a deadly new virus had been discovered, and had initiated an international effort to try to stop the epidemics in Zaire and Sudan, identify the virus, and determine how and why it had appeared. In a matter of days, what began as a problem in a missionary hospital would involve investigators and military personnel from eight countries, several international organizations, the foreign ministries of at least ten nations and the entire health apparatus of Zaire. Almost overnight, events would snowball into an effort necessitating over 500 skilled investigators, and mobilizing the resources of numerous European and American institutions, all at an indirect cost of over $10 million.
Direct costs for the Yambuku investigation alone would exceed $1 million.
The snowball effect began modestly enough on October 13, with Pierre Sureau's arrival in Kinshasa. The Pasteur Institute virologist represented WHO for the duration of the epidemic, and had the task of assisting Zairian authorities in any way possible. Sureau's first meeting was with Minister Ngwété Kikhela, who informed the French scientist that it would be several days before transport to Yambuku could be arranged. Such delays were to become a major component of this investigation, one that was constantly plagued not only by the mysterious virus but also by logistical nightmares aggravated by national panic. All commercial flights to Bumba had ceased as a result of the regional quarantine. That left only Zairian Air Force
transport to the region, but terrified pilots were rebelling against orders to enter the Bumba Zone.
Though his hopes of getting an immediate look at the Yambuku epidemic were thwarted, the spry, middle-aged French doctor was able to see a case of the disease on his first day in Zaire. Having nursed her dear friend Sister Myriam, Sister Edmonda now lay dying in Ngaliema Hospital's Pavilion 5 isolation ward. Sureau found her semi-delirious, severely dehydrated from days of diarrhea, feeble, anorexic, feverish, completely drained of energy; yet, surprisingly, unafraid.
“She knows what is coming. She has seen it before with Sister Myriam and all the cases in Yambuku. Yet she is calm,” Sureau noted, with considerable amazement.
Sister Edmonda thanked the doctor for his attention and “the good conversation,” and clutched the hand of an elderly Kinshasa nun, Sister Donatienne. Sureau took a blood sample and departed.
That night Sister Edmonda died.
“My God!” Sureau exclaimed. “That virus is fast!”
The following morning, October 14, Sureau returned to Ngaliema and discovered that a new patient had arrived. Student nurse Mayinga N'Seka, who had tended to both Sister Myriam and Sister Edmonda, was developing the first symptoms of the mysterious disease at about the time Sister Edmonda died. Two days earlier, Mayinga had spent hours in a general administrative office awaiting transit papers for overseas study, where she had contact with numerous strangers and officials. She then took a taxi to Mama Yemo Hospital, where she sat in a crowded waiting room, waiting for someone to treat her fever, headache, and muscle pains.
Sureau and Ngaliema doctors quickly determined that Mayinga had the Yambuku disease, and transferred her to Ngaliema's Pavilion 5 isolation ward. Concern and rumors started to spread through the streets of Kinshasa.
Meanwhile, WHO remained convinced the culprit could still be a strain of Marburg disease, so Sureau and Close contacted the South African team that had treated the Australian tourists a year earlier, asking for antiserum. The politics of such a request were dicey, and necessarily involved notifying the Mobutu government, South Africa's apartheid leaders, and the embassies of France and the United States. Though it violated Zaire's ban on relations with South Africa, all government representatives eventually agreed, for the sake of young Mayinga and the people of Yambuku, to allow Dr. Margaretha Isaacson to fly up from Johannesburg, Marburg antiserum in hand.
“It's our only hope,” Sureau told Zairian officials.
Talking incessantly, Isaacson hit the ground running and approached medicine like a field commander, ordering the Ngaliema medical troops about and bringing instant order to a scene that had been dangerously close to chaos. She and Sureau gave Mayinga the Marburg antiserum, and then the South African sat down with Zairian doctors to plan the transformation
of Pavilion 5 into a bona fide isolation ward. The Zairian medical staff, which had been in a state of extreme agitation ever since their colleague fell ill, was thrilled to see the “space suits” Isaacson brought from South Africa. Soon the entire staff of Pavilion 5 worked in head-to-toe white suits that had clear-plastic face coverings and respirators. The suits proved horrendously uncomfortable in the steamy Kinshasa heat, but the Ngaliema staff was enthusiastic about the protection.
They were far less enthusiastic about Isaacson's recommendation, supported by the Zairian Health Ministry, that the entire Pavilion 5 staff be placed under quarantine. Health Minister Ngwété made it clear his greatest concern was the possible spread of the Yambuku virus from Ngaliema Hospital into the streets of Kinshasa, endangering the 2 million residents of the capital. For nearly a month, a half dozen staff members would be confined to Pavilions 5 and 2 of Ngaliema Hospital, forbidden to leave the confines of the area to see their families.
Officials tracked down 37 people with whom Mayinga had shared meals or close contact in the days prior to her illness, placing all the unfortunate men, women, and children inside Pavilion 2 for twenty-one days of quarantine. One quarantined woman would give birth during her stay, and all the staff and isolated civilians would fight day-to-day personal battles against boredom, fear, and fatigue. In addition, 274 people who had had recent contact with the Pavilion-bound individuals were found, blood-tested, and kept under close surveillance.
Fortunately, no further cases of the Yambuku disease would develop in Kinshasa.
Years later, reflecting on the extreme precautions taken at Ngaliema Hospital, Isaacson would say that “perhaps we were overdoing things a little bit,” but “we could not afford doing less than the maximum precautions that were available. We could not do it ethically, we could not do it scientifically.”
Constantly abandoning all precautions—much to Isaacson's consternation—Sureau never wore a mask, and often spent long periods of time at Mayinga's bedside, chain-smoking cigarettes and dispensing calming conversation. Despite huge cultural and generational gaps, the student nurse and the physician became close, and Sureau often voiced his increasingly urgent hope that the Marburg antiserum would save his new friend. Mayinga herself was far from optimistic. Having seen the agony the Sisters had endured, she was frankly terrified.
“Dr. Isaacson is here,” Sureau told Mayinga gently. “She is one of the greatest experts in the world on Marburg. You are in very good hands. Have faith.”
Later, as he carefully prepared samples of Mayinga's blood for shipment to Pat Webb's CDC laboratory, Sureau could barely contain his excitement about the coming trip to Yambuku.
“For the community of arbovirologists, this is one of the greatest events
in contemporary epidemiology,” he noted in his diary. “No one of us would pass up such an opportunity for passionate study. Personally, I am delighted to be in this place, and to participate in such an adventure.”
Sureau's enthusiasm was tempered the following day, however, when Mayinga's condition deteriorated. Isaacson decided to try a second dose of the precious antiserum, and Sureau again comforted Mayinga by telling her that Isaacson was an expert. But by then the French and South African physicians knew the truth: whatever was infecting Mayinga was
not
the Marburg virus.
On October 18, six weeks after the Yambuku epidemic began, the core of what would that day be dubbed the International Commission arrived. Loaded down with enormous crates of sophisticated laboratory equipment, a plastic isolator for research, state-of-the-art microscopes and protective gear came the Americans: Karl Johnson and Joel Breman of the CDC's Special Pathogens Branch. Still in her maximum-security Atlanta laboratory, Patricia Webb was steaming mad. Just days before her planned departure, CDC director David Sencer had decided the job was “too big,” and leadership of the mission was awarded not to the woman, but to her husband.
The Machupo legends had preceded Johnson to Kinshasa, and Sureau's admiration for the man who discovered and survived Bolivian hemorrhagic fever was undisguised. Now a middle-aged veteran of dozens of CDC investigations, Johnson carried himself with a reasoned calm that inspired confidence in the men around him. He would be the foreman for an often adventuristic bunch of disease cowboys. Johnson, Breman, and Sureau became instant friends, and everyone, including the Zairois, deferred to Johnson's leadership.
By the end of the day the core of the International Commission was in place, and its first meeting convened (tensions eased by ample quantities of French wine) at five o'clock in the evening, October 18, chaired by Minister Ngwété. Present were six Zairois, including Omombo, whose twenty-four-hour visit to the Yambuku Mission had dramatically raised levels of anxiety in Kinshasa government circles. Representing WHO were Sureau, smallpox expert René Collas, and two Zaire-based European physicians. The five-man Belgian contingent included Stefan Pattyn and Peter Piot. One South African (Isaacson) and one official French representative (Gilbert Raffier) were present. And Americans Johnson, Close, and Breman were joined by Dr. John Kennedy of the U.S. Embassy. In coming weeks this core group would guide nearly all Yambuku-related activities, operating in several languages, crossing often difficult political and cultural boundaries, each professional adhering to his or her designated responsibilities and all answerable to the acerbic, often flat-out outrageous Johnson.
Niceties and introductions taken care of, Johnson swiftly guided the multilingual group through its marching orders, delegating responsibilities and laying out a strategy for attack that drew heavily from experiences with
Machupo and Lassa. Breman was put in charge of epidemiology investigations: doing the detective work necessary to determine who was spreading the disease, how, and with what clinical results. Together with Belgian Jean-François Ruppol, Piot, Zairian scientist André Koth, and Sureau, Breman was told to prepare for immediate departure for Yambuku.
Johnson reminded the group that the virus they were dealing with was extraordinarily dangerous, and using colorful language peppered with obscenities, ordered everyone to take their temperature twice a day, follow to the letter Isaacson's recommendations for protection, and always work in teams.
That night Piot, Sureau, and Breman prepared, each in his own way, for the next day's journey to Bumba. Young Piot, who had never before set foot outside Europe, was anxious to get out of the wedding suit his government had instructed him to wear, and see the infamous nightlife of Kinshasa. All night long the Belgian doctor strolled the streets of the city, chattering incessantly with the friendly Zairois, listening to the
ramba
rhythms in nightclubs, and sampling local drinks and delicacies.
“This is wonderful!” Piot exclaimed to local team members who showed him the town. “What an exciting place.”
He didn't want to sleep, or think about the epidemic. Piot arrived at the airport the following morning groggy and caffeine-sobered. Though sleepy, he grew increasingly alert as the time for the team's departure drew closer.
Sureau was also excited as he sat in the President's plane awaiting takeoff.
He had to admit, however, that he was “a little scared of the unknown,” and had been in no mood to party all night with the young Belgian. Instead, Sureau had paid another visit to Mayinga, finding her condition further deteriorated. The young student nurse was emotionally overwrought. He reviewed virus containment and protection procedures with Isaacson. And from her got a copy of
Marburg Virus Disease
by Martini and Siegert,
12
which he was now trying to read aboard the Hercules jet.
Breman, feeling the dull disorientation of jet lag, had spent the evening working out logistics with Johnson and Ruppol and making sure the proper equipment found its way into the plane's cargo bay.
After a three-hour flight the jet landed on Bumba's tiny airstrip. The terrified Air Force pilots left the engines running and ordered the scientists to get out as quickly as possible. Piot drove their Land-Rover, packed with supplies, out of the cargo hold, and hadn't even parked it before the panicky pilots began to taxi for takeoff.
Piot could feel the eyes of hundreds of people upon them as he inspected the Land-Rover. The airstrip was lined many rows deep with anxious-looking people.
“My God, the entire town must be here,” he whispered to Sureau.
“They've been under quarantine for days,” Breman reminded his colleagues.
“They're fed up, and they're scared. I imagine they think we're going to perform some kind of miracle.”
That night the scientific team shared the hospitality of Catholic missionaries in Bumba, who brought them up to date on radio messages from Yambuku. Bumba physicians Ngoi Mushola, Zayemba Tshiama, and Makuta briefed the foreigners on their clinical observations, noting that the epidemic had spread to several villages around Yambuku.
Sureau passed the final hours before retiring that night in quiet discussion with the grief-stricken priests of Bumba. Joel and Peter, however, were too high on adrenaline and curiosity to sip vermouth with aging clerics, so they went to a folk music festival at the local cathedral.
The following morning the group looked in on a handful of mystery disease patients at the Bumba hospital, and, fortuitously, met Dr. Massamba Matondo, chief physician for the neighboring Lisala province. Massamba, a careful doctor with an instinct for epidemiology, had already toured the epidemic area and he told Sureau the disease was claiming residents of at least forty-four villages in a fifty-mile radius around Yambuku.

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