The Coming Plague (25 page)
Authors: Laurie Garrett
Don Francis was burned out before he ever got involved in the Sudan episode. Hell, he was burned out before he even got to Harvard.
After two years of chasing down smallpox cases all over Sudan, India, and Bangladesh he was ready for a break. September 1975 found Francis at Harvard University, working on a Ph.D. in virology. With the CDC's permission, Francis was studying in Max Essex's laboratory when the Ebola mystery started unfolding some ten thousand miles away.
When CDC officers called him in October 1976, Francis was a bit flattered at first.
Francis got off the phone and searched out his mentor, Max Essex. He found the Rhode Island-born Yankee, as usual, poring over data, and requested a two-week leave from doctoral studies.
Essex agreed to let Francis take two weeks off; indeed, he later had to talk Don into going when the younger scientist's ego was bruised by learning that, far from being indispensable, he was the CDC's last resort. Every other person on the agency's list had turned down the assignment out of fear.
Word from Zaire had, by early November, been exaggerated in the gossip mills of international virology and finding eager volunteers for the Sudan investigation proved exceedingly difficult. Eventually WHO's Paul Brès gave up his search, bought a GenevaâNairobi ticket, and assigned himself to the investigation. The WHO team in Maridi would be composed of David Smith (of the Kenyan Ministry of Health), Don Francis, Bres, Irishman David Simpson (of the London School of Hygiene and Tropical Medicine), animal expert Barney Highton (also of the Kenyan Ministry of Health), and Sudanese medical experts Babiker El Tahir, Isaiah Mayom Deng, and Pacifico Lolik. Most would join Francis and Simpson in the south, having made their own way to Maridi via Nairobi or Juba ⦠after several days' delay.
Because of the ancient rift between Khartoum and the southern Sudanese
provinces, the federal government decided to stop the epidemic by completely cutting the south off from the rest of the country. It was sort of a damage control approach: many might die in the remote south, but the disease would not reach the more densely populated Muslim north. Absolutely no airplanes, trucks, or other vehicles were allowed in or out of the southern section of the country.
provinces, the federal government decided to stop the epidemic by completely cutting the south off from the rest of the country. It was sort of a damage control approach: many might die in the remote south, but the disease would not reach the more densely populated Muslim north. Absolutely no airplanes, trucks, or other vehicles were allowed in or out of the southern section of the country.
For four days Francis and Simpson begged, cajoled, and bribed their way around Khartoum, searching for a way to get themselvesâwith a couple of tons of suppliesâpast the quarantine lines, all the way south to Maridi and N'zara. Simpson, El Tahir, and Francis visited all the Western embassies, pleading for assistance. Much was promised, little materialized. Chartering a private airplane was ruled out: Khartoum and Kenyan officials insisted the entire aircraft would be burned, as a protection against contagion, upon return from the quarantine area.
At long last two large British trucks were found, loaded up, and filled with extra tanks of gas. Unbeknownst to the hapless
WHO
crew, McCormick had already left N'zara by the time Francis finally got behind the wheel of a truck bound for Maridi. It was the rainy season, and what passed for roads had become muddy rivulets. For twelve hours the
WHO
team kept their trucks in four-wheel drive and their accelerators floored and endured a battering, crashing ride. It was two in the morning when the exhausted group pulled into the town of Maridi, population 2,000.
WHO
crew, McCormick had already left N'zara by the time Francis finally got behind the wheel of a truck bound for Maridi. It was the rainy season, and what passed for roads had become muddy rivulets. For twelve hours the
WHO
team kept their trucks in four-wheel drive and their accelerators floored and endured a battering, crashing ride. It was two in the morning when the exhausted group pulled into the town of Maridi, population 2,000.
They were greeted by the Maridi hospital's night watchman, who awoke the town's two public health doctors and installed the tired team in an old British missionary complex.
The following day further impediments to their investigation mounted, and Francis, Simpson, and El Tahir were frankly stunned by the scale of their problems. The national quarantine of the south was bringing on near-famine conditions in the region. Because the rolling elephant grass savanna was often wet and marshy, it was insect-infested. Tsetse flies, in particular, swarmed about, infecting livestock and people with the trypanosomes that cause sleeping sickness. The problem was so severe that most people had years earlier ceased raising animals, and the entire region was dependent upon shipments of meat and protein from the north. No shipments had come through since September 30, when the quarantine was imposed. El Tahir, who had made the first official visit to the epidemic area on September 26, could clearly see the enormous difficulties imposed on the people by six weeks of quarantine.
The three men also found the distances between villages in the region lengthy and untraversable in four-wheel-drive vehicles. Some of the nomadic villages were virtually invisible, hidden in tall stands of elephant grass, reachable only by nearly imperceptible footpaths.
The district's headquarters, Maridi, was a sparsely supplied government town whose sole significant employer was a UNICEF-funded teaching hospital. Constructed of wattle, the hospital was staffed by two poorly paid
public health doctors and 120 nurses, most of whom were trainees. Their shared skills and supplies pretty much limited the Maridi staff to tender loving care in their constant war against sleeping sickness, malaria, bacterial meningitis, septicemic plague, relapsing fever, and a host of other tropical diseases. Long cut off from the rest of the world, Maridi had no telephones, so a ham radio was used to relay signals to Juba, where a French scientist remained throughout the Sudan investigation, serving as a communications officer, relaying messages to and from Khartoum. There was no communication with International Commission members in Zaire.
public health doctors and 120 nurses, most of whom were trainees. Their shared skills and supplies pretty much limited the Maridi staff to tender loving care in their constant war against sleeping sickness, malaria, bacterial meningitis, septicemic plague, relapsing fever, and a host of other tropical diseases. Long cut off from the rest of the world, Maridi had no telephones, so a ham radio was used to relay signals to Juba, where a French scientist remained throughout the Sudan investigation, serving as a communications officer, relaying messages to and from Khartoum. There was no communication with International Commission members in Zaire.
When Francis, Simpson, and El Tahir arrived, the two Maridi doctors were already in the process of closing their hospital, most of the nursing staff having either died of the new hemorrhagic fever or run away in fear, carrying the virus and panic with them back to the villages. The handful of nurses who remained were in the process of closing down the regular hospital facilities and tending to Ebola cases in a specially constructed wattle quarantine building.
Wearing respirators, protective gowns, and gloves, Simpson and Francis inspected the hospital and were horrified by their first sight of Ebola. Neither Francis nor the more experienced Irish physician, Simpson, had ever seen anything even approaching its devastation. Weak, emaciated men and women lay about the mud-and-stick chamber, staring out of ghost eyes at the white men. The virus was so toxic that it caused their hair, fingernails, and skin to fall off. Those who healed grew new skin.
Over the following days Francis, the epidemiologist of the group, questioned hundreds of people in the Maridi area, using local schoolteachers as translators. He drew many blood samples and mapped how the epidemic had spread. Barney Highton led efforts to capture animals and insects, hoping to discover the natural reservoir of the Ebola virus, and El Tahir set up a laboratory inside the abandoned Maridi hospital.
They soon discovered that the major sources of the continuing spread of the virus were the funerals; more specifically, the proceduresânot unlike those practiced in Yambukuâused to cleanse the bodies before burial. Francis ordered a halt to all the funerals of Ebola victims, promising that his team would cleanse the bodies according to tribal customs.
The people were outraged, and their collective anger nearly destroyed the entire WHO effort.
“I think they're going to kill us,” Francis told his colleagues. “I mean it. Watch your backs.”
Fortunately, one of Maridi's public health doctors was the son of a powerful local chief, and with the leader's support the people were eventually coaxed into bringing their dead to Maridi. Francis, Simpson, El Tahir, and Bres would take the bodies a discreet distance away from public view, put on their protective clothing, gloves, and respirators, and remove all undigested food and excreta from the cadavers, as prescribed by tribal custom, which entailed hand removal and manipulation of wastes without
evisceration. They would also carefully remove tissue and organ samples for laboratory analysis.
evisceration. They would also carefully remove tissue and organ samples for laboratory analysis.
Stopping the funeral cleansings and closing the hospital brought the Maridi epidemic to a halt, so Francis and El Tahir made their way to the even more remote town of N'zara. There Don found Joe McCormick's boxed note, guiding them through the sequence of original Ebola cases.
“Hi Don,” the note read. “Found your index case.” After providing details, it was signed simply, “Joe.”
N'zara was the hub for a population of about 20,000 people, most of whom lived in village clusters of mud huts scattered throughout the surrounding savannas and jungle. The economic center of N'zara was a cotton factory, where some 2,000 men made fabric from locally grown cotton using nineteenth-century machines. Inside the factory conditions were harsh; the tin roof magnified the excruciating equatorial heat, lung-damaging cotton fibers filled the air, bats swarmed out of the roofing periodically, filling parts of the factory with their malodorous guano, and the poorly paid men worked long, exhausting shifts.
McCormick's note explained who had been the first case in the mysterious epidemic and traced the order of subsequent infections. On June 27, well before the apparent onset of the Yambuku epidemic, a man who worked in the N'zara cotton mill fell ill and died on July 6 of hemorrhaging. His death was soon followed by those of two co-workers whose jobs were in the factory's cloth room, the same site where the first man worked. By July about two factory workers each week contracted the virus. By September several workers and their friends and family members had contracted Ebola, and at least thirty-five had died.
Two-thirds of the subsequent Ebola cases in N'zara involved a man named Ugawa, who was comparatively wealthy because he ran N'zara's cultural hub, a jazz club. The factory workers would spend much of their earnings in Ugawa's club, eating, drinking, and buying the sexual favors of the barmaids. Most of N'zara's epidemic evolved from those liaisons.
And it was Ugawa who had enough money to travel to the Maridi hospital when he came down with the disease. Once his virus got into the Maridi hospital, it spread like wildfire.
By the time the
WHO
team arrived in N'zara in mid-November, the epidemic was on its way out, having sickened over a third of the Maridi hospital staff, forty-one of whom died. It threw the hospital into chaos, from which many staffers fled. Nearly all the staff that got the disease were infected on the job, primarily through exposure to sick patients' fluids.
WHO
team arrived in N'zara in mid-November, the epidemic was on its way out, having sickened over a third of the Maridi hospital staff, forty-one of whom died. It threw the hospital into chaos, from which many staffers fled. Nearly all the staff that got the disease were infected on the job, primarily through exposure to sick patients' fluids.
From the staff, the epidemic spread into the community through several generations of transmission. Later investigations would reveal that the N'zara virus was highly contagious, spreading more than eight generations from the index case, as the scientists put it. The Yambuku strain, in contrast, never spread more than four generations. On the other hand, the Yambuku virus was far more likely to kill those it infected.
By November 20 it seemed the epidemic was over, the spread having halted as a result of the hospital closures and changes in funeral practices. Francis totaled up his case list: 284 Ebola cases, 151 deaths, all but four cases occurring in either N'zara or Maridi. As McCormick had suggested in his report to the commission (which Francis could not see in the Sudan), the Sudan virus seemed less deadly. While upward of 90 percent of those infected in the Yambuku outbreak died, only about half (53 percent) of the Sudanese cases were fatal.
The center of Maridi's epidemic was the hospital, where nearly half of the people hospitalized for other reasons got the disease (93 of 213 patients) and the toll among the medical staff was high.
In N'zara, however, the virus seemed to come, somehow, from the cotton factory, and the
WHO
team devoted a great deal of time and attention to that building, where nearly a thousand men worked at any given time. Freshly picked cotton came in one end of the structure and was processed room by room into bolts of finished cloth.
WHO
team devoted a great deal of time and attention to that building, where nearly a thousand men worked at any given time. Freshly picked cotton came in one end of the structure and was processed room by room into bolts of finished cloth.
Blood tests showed the highest infection and death rates were among the twenty-four men employed in the cloth room: four deaths and five nonlethal cases, for an overall infection rate of 38 percent. Francis and Highton combed the room in search of an animal or insect that carried the Ebola virus. They had no way to test the animals in N'zara, so they were working blind, capturing anything that moved, removing vital organs, and placing them in liquid nitrogen. Eventually, the organs would reach Pat Webb's lab in Atlanta, where she would perform the tests necessary to determine whether any were Ebola-infected.
They found the cloth room heavily infested with bats, rats, cotton boll weevils, spiders, and numerous other insects. By December, Webb would give the WHO team disturbing news:
none
of the animal samples contained Ebola virus.
none
of the animal samples contained Ebola virus.
Thus, the origin of N'zara's epidemic remained a mystery.
Having already spent well over the requested two weeks in the epidemic zone, Francis was anxious to get back to Harvard. The CDC, however, cabled Khartoum to instruct Don to remain in Sudan. It wasn't until Christmastime that Francis, imbued with a bitterness toward CDC leaders that would color his future activities with the agency, returned to Boston, renegotiated an extension on his CDC leave, and set to work completing his Ph. D. research.
By then, Joe McCormick was back in Sierra Leone, setting up his primitive Lassa laboratory. Karl Johnson had returned to Atlanta. Months later, Pat Webb would get her long-desired taste for exotica fulfilled, when she volunteered to join McCormick's Lassa studies in Sierra Leone.
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