September 7, 1976
A TWENTY-ONE-YEAR-OLD Yale biology student by the name of John Nordyke woke up at dawn at the edge of a village north of Bumba, Zaire. Rolling over in his sweat-drenched sleeping bag, he stared out through the mesh flap of his nylon mountain tent, hearing the sounds of the tropical rain forest mixed with the noises of the awakening village. A slight breeze brought the warm, pungent odor of cow dung permeated with the acrid aroma of cooking fires. High above him he caught glimpses of monkeys skittering through the lush vegetation that shielded the sky from his view.
He had slept fitfully, and as he pulled himself upright, he was unsteady and weak. He felt distinctly worse than he had the night before, when he’d been hit by chills and fever an hour or so after dinner. He guessed he had malaria even though he’d been careful to take his chloroquine phosphate as prophylaxis against it. The problem was that it had been impossible to avoid the clouds of mosquitoe5 that emanated each evening from the hidden pools in the swampy jungle.
With a hesitant gait, he made his way into the village and inquired about the nearest clinic. An itinerant priest told him that there was Belgian mission hospital in Yambuku, a small town located a few kilometers to the east. Sick and frightened, John quickly broke camp
stuffed his tent and sleeping bag into his backpack and set out for Yambuku.
John had taken a six-month leave from college to photograph African animals, such as the highland gorilla, which were threatened by extinction. It had been his boyhood dream to emulate the famous nineteenth-century explorers who had originally opened the Dark Continent.
Yambuku was scarcely larger than the village he’d just left, and the mission hospital did not inspire confidence. It was no more than a meager collection of cinder-block buildings, all in dire need of repair. The roofs were either rusting corrugated metal or thatched like the native huts, and there seemed no signs of electricity.
After checking in with a nun, swathed in traditional attire, who spoke only French, John was sent to wait among a throng of natives in all states of debility and disease. Looking at the other patients, he wondered if he wasn’t likely to catch something worse than what he already had. Finally he was seen by a harried Belgian doctor who could speak a little English, though not much. The examination was rapid, and as John had already surmised, the diagnosis was a “touch” of malaria. The doctor ordered an injection of chloroquine and advised John to return if he didn’t feel better within the next day or so.
The examination over, John was sent into the treatment room to wait in line for his injection. It was at that point that he noticed the lack of aseptic technique. The nurse did not have disposable needles but merely rotated one of three syringes. John was certain that their short stay in the sterilizing solution was not nearly long enough to render them germ-free. Besides, the nurse fished them out of the fluid with her fingers. When it became his turn, he was tempted to say something, but his French was not fluent enough, and he knew he needed the medicine.
During the next few days, John was glad that he’d been silent since he soon was feeling better. He stayed in the Yambuku area, occupying himself by photographing the Budza tribesmen. They were avid hunters and eager to demonstrate their prowess to the blond foreigner. By the third day John was preparing to recommence his journey up the Zaire River, following Henry Stanley’s footsteps, when his health took a rapid turn for the worse. The first thing he noticed was a violent headache, followed in rapid succession by chills, fever, nausea and diarrhea. Hoping it would pass, he took to his tent and shivered through the night, dreaming of home with clean sheets and a bathroom down the hail. By morning he felt weak and dehydrated, having vomited several times in the darkness. With
great difficulty, he got his things together and made his way slowly to the mission hospital. When he arrived in the compound, he vomited bright red blood and collapsed on the clinic floor.
An hour later he woke in a room occupied by two other patients, both suffering from drug-resistant malaria.
The doctor, the same man who’d examined John on his previous visit, was alarmed by the severity of John’s condition and noted some curious additional symptoms: a strange rash over his chest and small surface hemorrhages in his eyes. Although the doctor’s diagnosis was still malaria, he was troubled. It was not a typical case. As an added precaution, he decided to include a course of chloramphenicol in case the boy had typhoid fever.
September 16, 1976
Dr. Lugasa, District Health Commissioner for the Bumba region, glanced out the open window of his office at the expanse of the Zaire River as it shimmered in the morning sunlight. He wished it was still called the Congo with all the mystery and excitement that name invoked. Then, forcing his mind back to work, he looked again at the letter he’d just received from the Yambuku Mission Hospital concerning the deaths of an American male, one John Nordyke, and of a visiting farmer from a plantation near the Ebola River. The mission doctor claimed that their deaths had been caused by an unknown infection that spread rapidly; two patients housed with the American, four members of the planter’s household who’d been caring for the farmer, and ten of the clinic’s outpatients had come down with severe cases of the same illness.
Dr. Lugasa knew that he had two choices. First, he could do nothing, which was undoubtedly the wisest choice. God knew what kind of rampant endemic diseases there were out there in the bush. His second option was to fill out the bewildering array of official forms reporting the incident to Kinshasa where someone like himself, but higher on the bureaucratic ladder, would probably decide it was prudent to do nothing. Of course Dr. Lugasa knew that if he elected to fill out the forms, he would then be obligated to journey up to Yambuku, an idea that was particularly odious to him at that particularly damp, hot time of year.
With a twinge of guilt, Dr. Lugasa let the onionskin letter slip into the wastebasket.
September 23, 1976
A week later Dr. Lugasa was nervously shifting his weight from one foot to the other as he watched the aged DC-3 aircraft land at the Bumba airport. First out was Dr. Bouchard, Dr. Lugasa’s superior from Kinshasa. The day before, Dr. Lugasa had telephoned Dr. Bouchard to inform him that he’d just received word that a serious outbreak of an unknown disease was in progress in the area around the Yambuku Mission Hospital. It was affecting not only the local inhabitants, but the hospital staff as well. He had not mentioned the letter he’d received some seven days before.
The two doctors greeted each other on the tarmac and then climbed into Dr. Lugasa’s Toyota Corolla. Dr. Bouchard asked if there was any more news from Yambuku. Dr. Lugasa cleared his throat, still upset about what he’d learned that morning from the wireless. Apparently eleven of the medical staff of seventeen were already dead, along with one hundred and fourteen villagers. The hospital was closed since there was no one well enough to run it.
Dr. Bouchard decided that the entire Bumba region had to be quarantined. He quickly made the necessary calls to Kinshasa and then told the reluctant Dr. Lugasa to arrange transportation for the next morning so they could visit Yambuku and assess the situation firsthand.
September 24, 1976
The following day when the two doctors pulled into the deserted courtyard of the Yambuku Mission Hospital they were greeted by an eerie stillness. A rat scampered along the balustrade of an empty porch, and a putrid odor assaulted their senses. Holding cotton handkerchiefs over their noses, they reluctantly got out of the Land Rover and gingerly looked into the nearest building. It contained two corpses, both beginning to decay in the heat. It wasn’t until they’d peered into the third building that they found someone still alive, a nurse delirious with fever. The doctors went into the deserted operating room and put on gloves, gowns and masks in a belated attempt to protect themselves. Still fearful for their own health, they tended to the sick nurse and then searched for more of the staff. Among nearly thirty dead, they found four other patients barely clinging to life.
Dr. Bouchard radioed Kinshasa and requested emergency aid from the Zairean Air Force to airlift several patients from the mission hospital back to the capital. But by the time the infectious disease department at the university hospital was consulted about how to isolate the patients during transport, only the nurse still lived. Isolation techniques would have to be excellent, Bouchard pointed out, because they were obviously dealing with a highly contagious and very deadly disease.
September 30, 1976
The Belgian nurse airlifted to Kinshasa died at 3:00 A.M. despite six days of massive supportive therapy. No diagnosis was made, but after the autopsy, samples of her blood, liver, spleen and brain were sent to the Institut de Medicine Tropical in Antwerp, Belgium; to the Centers for Disease Control in Atlanta, U.S.A.; and to the Microbiological Research Establishment in Porton Down, England. In the Yambuku area there were now two hundred ninety-four known cases of the illness, with a fatality rate of approximately ninety percent.
October 13, 1976
The Yambuku virus was isolated almost simultaneously at the three international laboratories. It was noted to be structurally similar to the Marburg virus, first seen in 1967 in a fatal outbreak in laboratory workers handling green monkeys from Uganda. The new virus, considerably more virulent than Marburg, was named Ebola after the Ebola River north of Bumba. It was thought to be the most deadly microorganism seen since the bubonic plague.
November 16, 1976
Two months after the initial outbreak, the unknown disease in Yambuku was considered successfully contained since no new cases had been reported in the area for several weeks.
December 3, 1976
The quarantine of the Bumba region was lifted and air service reinstated. The Ebola virus had evidently returned to its original
source. Where that source was remained a complete mystery. An international team of professionals, including Dr. Cyrill Dubchek of the Centers for Disease Control who had played a big role in localizing the Lassa Fever virus, had scoured the area, searching for a reservoir for the Ebola virus within mammals, birds, and insects. The virologists had no success whatsoever. Not even a clue.
Los Angeles, California
Dr. Rudolph Richter, a tall, dignified ophthalmologist originally from West Germany, and cofounder of the Richter Clinic in Los Angeles, adjusted his glasses and looked over the advertising proofs laid out on the circular table in the clinic’s conference room. To his right was his brother and partner, William, a business-school graduate, who was examining the proofs with equal attention. The material was for the next quarter’s drive for new prepaid subscribers to the clinic’s health-care plan. It was aimed at young people, who as a group were relatively healthy. That was where the real money was in the prepaid health-care business, William had been quick to point out.
Rudolph liked the proofs. It was the first good thing that had happened to him that day. It was a day that had begun badly with a fender-bender on the entrance to the San Diego freeway, resulting in a nasty dent in his new BMW. Then there was the emergency surgery that had backed up the clinic. Then there was the tragic AIDS patient with some weird complication who’d coughed in his face while he tried to examine the man’s retinas. And on top of everything else, he’d been bitten by one of the monkeys used in his ocular herpes project. What a day!
Rudolph picked up an ad scheduled for the L.A. Times Sunday Magazine. It was perfect. He nodded at William, who motioned for the ad man to continue. The next part of the presentation was a slick thirty-second TV spot slotted for the evening news. It portrayed carefree bikini-clad girls on a Malibu beach, playing volley ball with some handsome young men. It reminded Rudolph of an expensive Pepsi ad, though it extolled the concept of prepaid health maintenance as delivered by an organization like the Richter Clinic in contrast to conventional fee-for-service medicine.
Along with Rudolph and William were a handful of other staff
doctors, including Dr. Navarre, Chief of Medicine. They were all directors of the clinic and held small amounts of stock.
William cleared his throat and asked if there were any questions from the staff. There were none. After the advertising people had departed, the group voiced unanimous approval of what had been presented. Then, after a brief discussion about the construction of a new satellite clinic to deal with the increase in subscribers from the Newport Beach area, the meeting was adjourned.
Dr. Richter returned to his office and cheerfully tossed the advertising proofs into his briefcase. It was a sumptuous room, considering the relatively low professional salary he drew as a physician in the group. But his salary was just incidental remuneration compared to the profits from his percentage of the outstanding stock. Both the Richter Clinic and Dr. Rudolph Richter were in sound financial shape.
After catching up on his calls, Dr. Richter made rounds on his own postoperative inpatients: two retinal detachments with difficult medical histories. Both were doing well. On his way back to his office, he thought about how little surgery he was doing as the sole ophthalmologist of the clinic. It was disturbing, but with all the ophthalmologists in town, he was lucky to have what he did. He was thankful that his brother had talked him into the clinic idea eight years ago.
Changing his white coat for a blue blazer and picking up his briefcase, Dr. Richter left the clinic. It was after 9:00 P.M., and the two-tiered parking garage was almost empty. During the day it was always full, and William was already talking about the need to expand it, not only for the spaces but for the depreciation; issues like that Rudolph didn’t truly understand, nor did he want to.
Musing about the economics of the clinic, Dr. Richter was unaware of two men who had been waiting in the shadows of the garage. He remained unaware even after they fell in step behind him. The men were dressed in dark business suits. The taller of the two had an arm that seemed permanently frozen into a flexed position. In his hand was a fat briefcase that he held high due to the immobility of the elbow joint.
Nearing his car, Dr. Richter sensed the footsteps behind him as they quickened in pace. An uncomfortable sensation gripped his throat. He swallowed hard and cast a nervous glance over his shoulder. He caught sight of the two men, who seemed to be coming directly toward him. As they passed beneath an overhead light, Dr. Richter could appreciate that they were carefully dressed, with fresh shirts and silk ties. That made him feel a little better. Even so, he
moved more quickly, rounding the back end of his car. Fumbling for the keys, he unlocked the driver’s-side door, tossed in his briefcase, and slid into the welcome smell of coach leather. He started to close the door, when a hand stopped him. Dr. Richter reluctantly raised his eyes to what turned out to be the calm, blank face of one of the men who had followed him. The suggestion of a smile crossed the man’s countenance as Dr. Richter looked at him inquiringly.
Dr. Richter tried again to pull his door shut, but the man held it firmly from the outside.
“Could you tell me the time, doctor?” asked the man politely.
“Certainly,” said Richter, glad to have a safe explanation for the man’s presence. He glanced at his watch, but before he had a chance to speak, he felt himself rudely pulled from the car. He made a halfhearted effort to struggle, but he was quickly overwhelmed and stunned by an open-handed blow to the side of his face that knocked him to the ground. Hands roughly searched for his wallet, and he heard fabric tear. One of the men said “businessman,” in what sounded like a disparaging tone, while the other said, “Get the briefcase.” Dr. Richter felt his watch yanked from his wrist.
It was over as quickly as it had begun. Dr. Richter heard footsteps recede and a car door slam, then the screech of tires on the smooth concrete. For a few moments he lay without moving, glad to be alive. He found his glasses and put them on, noting that the left lens was cracked. As a surgeon, his primary concern was for his hands; they were the first thing he checked, even before he picked himself up off the ground. Getting to his feet, he began to examine the rest of himself. His white shirt and his tie were smeared with grease. A button was missing from the front of his blazer, and in its place was a small horseshoe-shaped tear. His pants were torn from the right front pocket all the way down to his knee.
“God, what a day!” he voiced to himself, thinking that being mugged made the morning’s fender-bender seem trivial by comparison. After a moment’s hesitation, he recovered his keys and returned to the clinic, going back to his office. He called security, then debated whether to call the L.A. police. The idea of bad publicity for the clinic made him hesitate, and really, what would the police have done? While he argued with himself, he called his wife to explain that he’d be a little later than expected. Then he went into the lavatory to examine his face in the mirror. There was an abrasion over the right cheekbone that was sprinkled with bits of parking-garage grit. As he gingerly blotted it with antiseptic, he tried to estimate how much he had contributed to the muggers’ welfare. He guessed he’d had about
a hundred dollars in his wallet as well as all his credit cards and identification, including his California medical license. But it was the watch that he most hated to lose; it had been a gift from his wife. Well, he could replace it, he thought, as he heard a knock on his outer door.
The security man was fawningly apologetic, saying that such a problem had never happened before, and that he wished he’d been in the area. He told Dr. Richter that he’d been through the garage only a half-hour before, on his normal rounds. Dr. Richter assured the man that he was not to blame and that his, Richter’s, only concern was that steps be taken to make certain that such an incident did not reoccur. The doctor then explained his reasons for not calling the police.
The following day, Dr. Richter did not feel well but he attributed the symptoms to shock and the fact that he’d slept poorly. By five-thirty, though, he felt ill enough to consider canceling a rendezvous he had with his mistress, a secretary in the medical records department. In the end, he went to her apartment but left early to get some rest, only to spend the night tossing restlessly in his bed.
The next day, Dr. Richter was really ill. When he stood up from the slit lamp, he was light-headed and dizzy. He tried not to think about the monkey bite or being coughed on by the AIDS patient. He was well aware that AIDS was not transmitted by such casual contact: it was the undiagnosed superinfection that worried him. By three-thirty he had a chill and the beginnings of a headache of migraine intensity. Thinking he had developed a fever, he canceled the rest of the afternoon’s appointments and left the clinic. By then he was quite certain he had the flu. When he arrived home, his wife took one look at his pale face and red-rimmed eyes, and sent him to bed. By eight o’clock, his headache was so bad that he took a Percodan. By nine, he had violent stomach cramps and diarrhea. His wife wanted to call Dr. Navarre, but Dr. Richter told her that she was being an alarmist and that he’d be fine. He took some Dalmane and fell asleep. At four o’clock he woke up and dragged himself into the bathroom, where he vomited blood. His terrified wife left him long enough to call an ambulance to take him to the clinic. He did not complain. He didn’t have the strength to complain. He knew that he was sicker than he’d ever been in his life.
SOMETHING DISTURBED MARISSA Blumenthal. Whether the stimulus came from within her own mind, or from some minor external change, she did not know. Nonetheless her concentration was broken. As she raised her eyes from the book in her lap she realized that the light outside the window had changed from its pale wintery white to inky blackness. She glanced at her watch. No wonder. It was nearly seven.
“Holy Toledo,” muttered Marissa, using one of her expressions left over from childhood. She stood up quickly and felt momentarily dizzy. She had been sprawled out on two low slung vinyl-covered chairs in a corner of the library of the Centers for Disease Control (CDC) in Atlanta for more hours than she cared to think about. She had made a date for that evening and had planned on being home by six-thirty to get ready.
Hefting Fields’ ponderous Virology textbook, she made her way over to the reserve shelf, stretching her cramped leg muscles en route. She’d run that morning, but had only put in two miles, not her usual four.
“Need help getting that monster on the shelf?” teased Mrs. Campbell, the motherly librarian, buttoning her omnipresent gray cardigan. It was none too warm in the library.
As in all good humor, there was some basis in truth for Mrs. Campbell’s whispered comment. The virology textbook weighed ten
pounds-one-tenth as much as Marissa’s hundred-pound frame. She was only five feet tall, although when people asked, she said she was five-two, though that was only in heels. To return the book, she had to swing it back and then almost toss it into place.
“The kind of help I need with this book,” said Marissa, “is to get the contents into my brain.”
Mrs. Campbell laughed in her subdued fashion. She was a warm, friendly person, like most everyone at CDC. As far as Marissa was concerned, the organization had more the feeling of an academic institution than a federal agency, which it had officially become in 1973. There was a pervading atmosphere of dedication and commitment. Although the secretaries and maintenance personnel left at four-thirty, the professional staff invariably stayed on, often working into the wee hours of the morning. People believed in what they were doing.
Marissa walked out of the library, which was hopelessly inadequate in terms of space. Half the Center’s books and periodicals were stored haphazardly in rooms all over the complex. In that sense the CDC was very much a federally regulated health agency, forced to scrounge for funding in an atmosphere of budget cutting. Marissa noted it also looked like a federal agency. The hall was painted a drab, institutional green, and the floor was covered in a gray vinyl that had been worn thin down the middle. By the elevator was the inevitable photograph of a smiling Ronald Reagan. Just beneath the picture someone had irreverently tacked up an index card that said: “If you don’t like this year’s appropriation, just wait until next year!”
Marissa took the stairs up one flight. Her office-it was generous to call it that; it was more cubbyhole than office-was on the floor above the library. It was a windowless storage area that might have been a broom closet at one time. The walls were painted cinder block, and there was just enough room for a metal desk, file cabinet, light and swivel chair. But she was lucky to have it. Competition for space at the Center was intense.
Yet despite the handicaps, Marissa was well aware that the CDC worked. It had delivered phenomenal medical service over the years, not only in the U.S., but in foreign countries as well. She remembered vividly how the Center had solved the Legionnaires Disease mystery a number of years back. There had been hundreds of such cases since the organization had been started in 1942 as the Office of Malaria Control to wipe out that disease in the American South. In 1946 it had been renamed the Communicable Disease Center, with separate labs set up for bacteria, fungi, parasites, viruses
and rickettsiae. The following year a lab was added for zoonoses, diseases that are animal ailments but that can be transmitted to man, like plague, rabies and anthrax. In 1970 the organization was renamed again, this time the Centers for Disease Control.
As Marissa arranged some articles in her government-issue briefcase, she thought about the past successes of the CDC, knowing that its history had been one of the prime reasons for her considering coming to the Center. After completing a pediatric residency in Boston, she had applied and had been accepted into the Epidemiology Intelligence Service (EIS) for a two-year hitch as an Epidemiology Intelligence Service Officer. It was like being a medical detective. Only three and a half weeks previously, just before Christmas, she’d completed her introductory course, which supposedly trained her for her new role. The course was in public-health administration, biostatistics and epidemiology-the study and control of health and disease in a given population.
A wry smile appeared on Marissa’s face as she pulled on her dark blue overcoat. She’d taken the introductory course, all right, but as had happened so often in her medical training, she felt totally unequipped to handle a real emergency. It was going to be an enormous leap from the classroom to the field if and when she was sent out on an assignment. Knowing how to relate to cases of a specific disease in a coherent narrative that would reveal cause, transmission and host factors was a far cry from deciding how to control a real outbreak involving real people and a real disease. Actually, it wasn’t a question of “if,” it was only a question of “when.”
Picking up her briefcase, Marissa turned off the light and headed back down the hall to the elevators. She’d taken the introductory epidemiology course with forty-eight other men and women, most of whom, like herself, were trained physicians. There were a few micro-biologists, a few nurses, even one dentist. She wondered if they all shared her current crisis of confidence. In medicine, people generally didn’t talk about such things; it was contrary to the “image.”
At the completion of the training, she’d been assigned to the Department of Virology, Special Pathogens Branch, her first choice among the positions available. She had been granted her request because she’d ranked number one in the class. Although Marissa had little background in virology, which was the reason she’d been spending so much time in the library, she’d asked to be assigned to the department because the current epidemic of AIDS had catapulted virology into the forefront of research. Previously it had
always played second fiddle to bacteriology. Now virology was where the “action” was, and Marissa wanted to be a part of it.
At the elevators, Marissa said hello to the small group of people who were waiting. She’d met some of them, mostly those from the Department of Virology, whose administrative office was just down the hail from her cubicle. Others were strangers, but everyone acknowledged her. She might have been experiencing a crisis of confidence in her professional competence, but at least she felt welcome.
On the main floor Marissa stood in line to sign out, a requirement after 5:00 P.M., then headed to the parking area. Although it was winter, it was nothing like what she’d endured in Boston for the previous four years, and she didn’t bother to button her coat. Her sporty red Honda Prelude was as she’d left it that morning: dusty, dirty and neglected. It still had Massachusetts license plates; replacing them was one of the many errands that Marissa had not yet found time to do.
It was a short drive from the CDC to Marissa’s rented house. The area around the Center was dominated by Emory University, which had donated the land to the CDC in the early ’40s. A number of pleasant residential neighborhoods surrounded the university, running the gamut from lower middle class to conspicuously rich. It was in one of the former neighborhoods, in the Druid Hills section, that Marissa had found a house to rent. It was owned by a couple who’d been transferred to Mali, Africa, to work on an extended birth-control project.
Marissa turned onto Peachtree Place. It seemed to her that everything in Atlanta was named “peachtree.” She passed her house on the left. It was a small two-story wood-frame building, reasonably maintained except for the grounds. The architectural style was in-determinant, except for two Ionic columns on the front porch. The windows all had fake shutters, each with a heart-shaped area cut out in the center. Marissa had used the term “cute” to describe it to her parents.
She turned left at the next street and then left again. The property on which the house sat went all the way through the block, and in order for Marissa to get to the garage, she had to approach from the rear. There was a circular drive in front of the house, but it didn’t connect with the rear driveway and the garage. Apparently in the past the two driveways had been connected, but someone had built a tennis court, and that had ended the connection. Now, the tennis court was so overgrown with weeds it was barely discernible.
Knowing that she was going out that evening, Marissa did not put
her car in the garage, but just swung around and backed it up. As she ran up the back steps, she heard the cocker spaniel, given to her by one of her pediatric colleagues, barking welcome.
Marissa had never planned on having a dog, but six months previously a long-term romantic relationship that she had assumed was leading to marriage had suddenly ended. The man, Roger Shulman, a neurosurgical resident at Mass. General, had shocked Marissa with the news that he had accepted a fellowship at UCLA and that he wanted to go by himself. Up until that time, they had agreed that Marissa would go wherever Roger went to finish his training, and indeed Marissa had applied for pediatric positions in San Francisco and Houston. Roger had never even mentioned UCLA.
As the baby in the family, with three older brothers and a cold and dominating neurosurgeon for a father, Marissa had never had much self-confidence. She took the breakup with Roger very badly and had been barely able to drag herself out of bed each morning to get to the hospital. In the midst of her resultant depression, her friend Nancy had presented her with the dog. At first Marissa had been irritated, but Taffy-the puppy had worn the cloyingly sweet name on a large bow tied around its neck-soon won Marissa’s heart, and, as Nancy had judged, it helped Marissa to focus on something besides her hurt. Now Marissa was crazy about the dog, enjoying having “life” in her home, an object to receive and return her love. Coming to the CDC, Marissa’s only worry had been what to do with Taffy when she was sent out in the field. The issue weighed heavily on her until the Judsons, her neighbors on the right, fell in love with the dog and offered-no, demanded-to take Taffy any time Marissa had to go out of town. It was like a godsend.
Opening the door, Marissa had to fend off Taffy’s excited jumps until she could turn off the alarm. When the owners had first explained the system to Marissa, she’d listened with only half an ear. But now she was glad she had it. Even though the suburbs were much safer than the city, she felt much more isolated at night than she had in Boston. She even appreciated the “panic button” that she carried in her coat pocket and which she could use to set off the alarm from the driveway if she saw unexpected lights or movement inside the house.
While Marissa looked over her mail, she let Taffy expend some of her pent-up energy racing in large circles around the blue spruce in the front yard. Without fail, the Judsons let the dog out around noon; still from then until Marissa got home in the evening was a long time for an eight-month-old puppy to be cooped up in the kitchen.
Unfortunately, Marissa had to cut Taffy’s exuberant exercise short. It was already after seven, and she was expected at dinner at eight. Ralph Hempston, a successful ophthalmologist, had taken her out several times, and though she still had not gotten over Roger, she enjoyed Ralph’s sophisticated company and the fact that he seemed content to take her to dinner, the theater, a concert without pressuring her to go to bed. In fact, tonight was the first time he’d invited her to his house, and he’d made it clear it was to be a large party, not just the two of them.
He seemed content to let the relationship grow at its own pace, and Marissa was grateful, even if she suspected the reason might be the twenty-two-year difference in their ages; she was thirty-one and he was fifty-three.
Oddly enough the only other man Marissa was dating in Atlanta was four years younger than she. Tad Schockley, a microbiologist Ph.D. who worked in the same department she ultimately had been assigned to, had been smitten by her the moment he’d spied her in the cafeteria during her first week at the Center. He was the exact opposite of Ralph Henipston: socially painfully shy, even when he’d only asked her to a movie. They’d gone out a half dozen times, and thankfully he, like Ralph, had not been pushy in a physical sense.
Showering quickly, Marissa then dried herself off and put on makeup almost automatically. Racing against time, she went through her closet, rapidly dismissing various combinations. She was no fashion plate but liked to look her best. She settled on a silk skirt and a sweater she’d gotten for Christmas. The sweater came down to midthigh, and she thought that it made her look taller. Slipping on a pair
of black pumps, she eyed herself in the full-length mirror.
Except for her height, Marissa was reasonably happy with her looks. Her features were small but delicate, and her father had actually used the term “exquisite” years ago when she’d asked him if he thought she was pretty. Her eyes were dark brown and thickly lashed, and her thick, wavy hair was the color of expensive sherry. She wore it as she had since she was sixteen: shoulder length, and pulled back from her forehead with a tortoiseshell barrette.
It was only a five-minute drive to Ralph’s, but the neighborhood changed significantly for the better. The houses grew larger and were set back on well-manicured lawns. Ralph’s house was situated on a large piece of property, with the driveway curving gracefully up from the street. The drive was lined with azaleas and rhododendrons that in the spring had to be seen to be believed, according to Ralph.
The house itself was a three-story Victorian affair with an octagonal
tower dominating the right front corner. A large porch, defined by complicated gingerbread trim, started at the tower, extended along the front of the house and swept around the left side. Above the double-doored front entrance and resting on the roof of the porch was a circular balcony roofed with a cone that complemented the one on top of the tower.
The scene looked festive enough. Every window in the house blazed with light. Marissa drove around to the left, following Ralph’s instructions. She thought that she was a little late, but there were no other cars.
As she passed the house, she glanced up at the fire escape coming down from the third floor. She’d noticed it one night when Ralph had stopped to pick up his forgotten beeper. He’d explained that the previous owner had made servants’ quarters up there, and the city building department had forced him to add the fire escape. The black iron stood out grotesquely against the white wood.
Marissa parked in front of the garage, whose complicated trim matched that of the house. She knocked on the back door, which was in a modern wing that could not be seen from the front. No one seemed to hear her. Looking through the window, she could see a lot of activity in the kitchen. Deciding against trying the door to see if it was unlocked, she walked around to the front of the house and rang the bell. Ralph opened the door immediately and greeted her with a big hug.
“Thanks for coming over early,” he said, helping her off with her coat.
“Early? I thought I was late.”
“No, not at all,” said Ralph. “The guests aren’t supposed to be here until eight-thirty.” He hung her coat in the hail closet.
Marissa was surprised to see that Ralph was dressed in a tuxedo. Although she’d acknowledged how handsome he looked, she was disconcerted.
“I hope I’m dressed appropriately,” she said. “You didn’t mention that this was a formal affair.”
“You look stunning, as always. I just like an excuse to wear my tux. Come, let me show you around.”
Marissa followed, thinking again that Ralph looked the quintessential physician: strong, sympathetic features and hair graying in just the right places. The two walked into the parlor, Ralph leading the way. The decor was attractive but somewhat sterile. A maid in a black uniform was putting out hors d’oeuvres. “We’ll begin in here. The drinks will be made at the bar in the living room,” Ralph said.
He opened a pair of sliding-panel doors, and they stepped into the living room. A bar was to the left. A young man in a red vest was busily polishing the glassware. Beyond the living room, through an arch, was the formal dining room. Marissa could see that the table was laid for at least a dozen people.
She followed Ralph through the dining room and out into the new wing, which contained a family room and a large modern kitchen. The dinner party was being catered, and three or four people were busy with the preparations.
After being reassured that everything was under control, Ralph led Marissa back to the parlor and explained that he’d asked her to come over early in hopes that she’d act as hostess. A little surprised- after all, she’d only been out with Ralph five or six times-Marissa agreed.
The doorbell rang. The first guests had arrived.
Unfortunately, Marissa had never been good at keeping track of people’s names, but she remembered a Dr. and Mrs. Hayward because of his astonishingly silver hair. Then there was a Dr. and Mrs. Jackson, she sporting a diamond the size of a golf ball. The only other names Marissa recalled afterward were Dr. and Dr. Sandberg, both psychiatrists.
Making an attempt at small talk, Marissa was awed by the furs and jewels. These people were not small-town practitioners.
When almost everyone was standing in the living room with a
drink in hand, the doorbell sounded again. Ralph was not in sight, so
Marissa opened the door. To her utter surprise she recognized Dr.
Cyrill Dubchek, her boss at the Special Pathogens Branch of the
Department of Virology.
“Hello, Dr. Blumenthal,” said Dubchek comfortably, taking Manssa’s presence in stride.
Marissa was visibly flustered. She’d not expected anyone from the CDC. Dubchek handed his coat to the maid, revealing a dark blue Italian-tailored suit. He was a striking man with coal black, intelligent eyes and an olive complexion. His features were sharp and aristocratic. Running a hand through his hair, which was brushed straight back from his forehead, he smiled. “We meet again.”
Marissa weakly returned the smile and nodded toward the living room. “The bar is in there.”
“Where’s Ralph?” asked Dubchek, glancing into the crowded living room.
“Probably in the kitchen,” said Marissa.
Dubchek nodded, and moved off as the doorbell rang again. This
time Marissa was even more flabbergasted. Standing before her was Tad Schockley!
“Marissa!” said Tad, genuinely surprised.
Marissa recovered and allowed Tad to enter. While she took his coat, she asked, “How do you know Dr. Hempston?”
“Just from meetings. I was surprised when I got an invitation in the mail.” Tad smiled. “But who am I to turn down a free meal, on my salary?”
“Did you know that Dubchek was coming?” asked Manissa. Her tone was almost accusing.
Tad shook his head. “But what difference does it make?” He looked into the dining room and then up the main staircase. “Beautiful house. Wow!”
Marissa grinned in spite of herself. Tad, with his short sandy hair and fresh complexion, looked too young to be Ph.D. He was dressed in a corduroy jacket, a woven tie and gray flannels so worn, they might as well have been jeans.
“Hey,” he said. “How do you know Dr. Hempston?”
“He’s just a friend,” said Marissa evasively, gesturing for Tad to head into the living room for a drink.
Once all the guests had arrived, Marissa felt free to move away from the front door. At the bar, she got herself a glass of white wine and tried to mingle. Just before the group was summoned into the dining room, she found herself in a conversation with Dr. Sandberg and Dr. and Mrs. Jackson.
“Welcome to Atlanta, young lady,” said Dr. Sandberg.
“Thank you,” said Marissa, trying not to gawk at Mrs. Jackson’s ring.
“How is it you happened to come to the CDC?” asked Dr. Jackson. His voice was deep and resonant. He not only looked like Charlton Heston; he actually sounded as if he could play Ben Hur.
Looking into the man’s deep blue eyes, she wondered how to answer his seemingly sincere question. She certainly wasn’t going to mention anything about her former lover’s flight to L.A. and her need for a change. That wasn’t the kind of commitment people expected at the CDC. “I’ve always had an interest in public health.” That was a little white lie. “I’ve always been fascinated by stories of medical detective work.” She smiled. At least that was the truth. “I guess I got tired of looking up runny noses and into draining ears.”
“Trained in pediatrics,” said Dr. Sandberg. It was a statement, not a question.
“Children’s Hospital in Boston,” said Marissa. She always felt a
little ill at ease talking with psychiatrists. She couldn’t help but wonder if they could analyze her motives better than she could herself. She knew that part of the reason she had gone into medicine was to enable her to compete with her brothers in their relationships with their father.
“How do you feel about clinical medicine?” asked Dr. Jackson. “Were you ever interested in practicing?”
“Well, certainly,” replied Marissa.
“How?” continued Dr. Jackson, unknowingly making Marissa feel progressively uneasy. “Did you see yourself solo, in a group, or in a clinic?”
“Dinner is served,” called Ralph over the din of conversation.
Manissa felt relieved as Dr. Jackson and Dr. Sandberg turned to find their wives. For a moment she had felt as if she were being interrogated.
In the dining room Marissa discovered that Ralph had seated himself at one end of the table and had placed her at the other. To her immediate right was Dr. Jackson, who thankfully forgot about his questions concerning clinical medicine. To her left was the silver-haired Dr. Hayward.
As the meal progressed, it became even clearer that Marissa was dining with the cream of Atlanta’s medical community. These were not just doctors; they were the most successful private practitioners in the city. The only exceptions to this were Cyrill Dubchek, Tad and herself.
After several glasses of good wine, Marissa was more talkative than normal. She felt a twinge of embarrassment when she realized that the entire table was listening to her description of her childhood in Virginia. She told herself to shut up and smile, and she was pleased when the conversation switched to the sorry state of American medicine and how prepaid health-care groups were eroding the foundations of private practice. Remembering the furs and jewels, Marissa didn’t feel that those present were suffering too much.
“How about the CDC?” asked Dr. Hayward, looking across at Cyrill. “Have you been experiencing budgetary constraints?”
Cyrill laughed cynically, his smile forming deep creases in his cheeks. “Every year we have to do battle with the Office of Management and Budget as well as the House Appropriations Committee. We’ve lost five hundred positions due to budgetary cuts.”
Dr. Jackson cleared his throat: “What if there were a serious outbreak of influenza like the pandemic of 1917-1918. Assuming your
department would be involved, do you have the manpower for such an eventuality?”
Cyrill shrugged. “It depends on a lot of variables. If the strain doesn’t mutate its surface antigens and we can grow it readily in tissue culture, we could develop a vaccine quite quickly. How quickly, I’m not sure. Tad?”
“A month or so,” said Tad, “if we were lucky. More time to produce enough to make a significant difference.”
“Reminds me of the swine flu fiasco a few years ago,” interjected Dr. Hayward.
“That wasn’t the CDC’s fault,” said Cyrill defensively. “There was no doubt about the strain that appeared at Fort Dix. Why it didn’t spread is anybody’s guess.”
Marissa felt a hand on her shoulder. Turning, she found herself looking at one of the black-dressed waitresses.
“Dr. Blumenthal?” whispered the girl.
“There is a phone call for you.”
Marissa glanced down the table at Ralph, but he was busy talking with Mrs. Jackson. She excused herself and followed the girl to the kitchen. Then it dawned on her, and she felt a stirring of fear, like the first time she had been called at night as an intern: It had to be the CDC. After all, she was on call and she’d dutifully left Ralph’s number. No one else knew she was there.
“Dr. Blumenthal?” asked the CDC operator, when Marissa picked up the phone.
The call was switched to the duty officer. “Congratulations,” he said jovially. “There has been an epidemic aid request. We had a call from the California State Epidemiologist, who would like CDC help on a problem in L.A. It’s an outbreak of unknown but apparently serious illness in a hospital called the Richter Clinic. We’ve gone ahead and made a reservation for you on Delta’s flight to the coast that leaves at 1:10 A.M. We’ve arranged hotel accommodations at a place called the Tropic Motel. Sounds divine. Anyway, good luck!”
Replacing the receiver, Marissa left her hand on the phone for a moment while she caught her breath. She didn’t feel prepared at all. Those poor, unsuspecting people in California had called the CDC expecting to get an epidemiologic expert, and instead, they were going to get her, Marissa Blumenthal. All five feet of her. She made her way back to the dining room to excuse herself and say good-bye.
BY THE TIME MARISSA had gotten her suitcase from the baggage carousel, waited for the rent-a-car van, gotten the rent-a-car (the first one wouldn’t start), and had somehow managed to find the Tropic Motel, the sky had begun to lighten.
As she signed in, she couldn’t help thinking of Roger. But she wouldn’t call. She’d promised herself that much several times on the flight.
The motel was depressing, but it didn’t matter. Marissa didn’t think she’d be spending much time there. She washed her hands and face, combed her hair and replaced her barrette. With no other plausible reason for delay, she returned to the rent-a-car and set out for the Richter Clinic. The palms of her hands were damp against the steering wheel.
The clinic was conveniently situated on a wide thoroughfare. There were few cars at that time of morning. Marissa pulled into a parking garage, took a ticket and found a spot near the entrance. The entire structure was modern, including the garage, the clinic, and what Marissa guessed was the hospital, which appeared to be seven stories tall. Getting out of the car, she stretched, then lifted out her briefcase. In it were her class notes from the epidemiology portion of the introductory course-as if that would be any help-a note pad, pencils, a small textbook on diagnostic virology, an extra lipstick and a pack of chewing gum. What a joke.
Once inside, Marissa noted the familiar hospital odor of disinfectant-a smell that somehow calmed her and made her feel instantly at home. There was an information booth, but it was empty. She asked a maintenance man mopping the floor how to get to the hospital wing, and he pointed to a red stripe on the floor. Marissa followed it to the emergency room. There was little activity there, with few patients in the waiting room and only two nurses behind the main desk. Marissa sought out the on-call doctor and explained who she was.
“Oh, great!” said the ER doctor enthusiastically. “Are we glad you’re here! Dr. Navarre has been waiting all night for you. Let me get him.”
Marissa absentmindedly played with some paper clips. When she looked up, she realized the two nurses were staring at her. She smiled and they smiled back.
“Can I get you some coffee?” asked the taller of the two.
“That would be nice,” said Marissa. In addition to her basic anxiety, she was feeling the effects of only two hours of fitful sleep on the flight from Atlanta.
Sipping the hot liquid, Marissa recalled the Berton Roueche medical detective stories in The New Yorker. She wished that she could be involved in a case like the one solved by John Snow, the father of modern epidemiology: A London cholera epidemic was aborted when Snow deductively isolated the problem to a particular London water pump. The real beauty of Snow’s work was that he did it before the germ theory of disease was accepted. Wouldn’t it be wonderful to be involved in such a clear-cut situation?
The door to the on-call room opened, and a handsome, black-haired man appeared. Blinking in the bright ER light, he came directly toward Marissa. The corners of his mouth pulled up in a big smile. “Dr. Blumenthal, we are so glad to see you. You have no idea.”
As they shook hands, Dr. Navarre gazed down at Marissa. Standing next to her, he was momentarily taken aback by her diminutive size and youthful appearance. To be polite, he inquired about her flight and asked if she was hungry.
“I think it would be best to get right down to business,” said Marissa.
Dr. Navarre readily agreed. As he led Marissa to the hospital conference room, he introduced himself as chief of the department of medicine. This news didn’t help Marissa’s confidence. She recognized that Dr. Navarre undoubtedly knew a hundred times more than she about infectious disease.
Motioning for Marissa to sit at the round conference table, Dr. Navarre picked up the phone and dialed. While the call was going through, he explained that Dr. Spenser Cox, the State Epidemiologist was extremely eager to talk to Marissa the moment she’d arrived.
Wonderful, thought Marissa, forcing a weak smile.
Dr. Cox sounded equally as happy as Dr. Navarre that Marissa was there. He explained to her that unfortunately he was currently embroiled in a problem in the San Francisco Bay area involving an outbreak of hepatitis B that they thought could be related to AIDS.
“I assume,” continued Dr. Cox, “that Dr. Navarre has told you that the problem at the Richter Clinic currently involves only seven patients.”
“He hasn’t told me anything yet,” said Marissa.
“I’m sure he is just about to,” said Dr. Cox. “Up here, we have almost five hundred cases of hepatitis B, so you can understand why I can’t come down there immediately.”
“Of course,” said Marissa.
“Good luck,” said Dr. Cox. “By the way, how long have you been with the CDC?”
“Not that long,” admitted Marissa.
There was a short pause. “Well, keep me informed,” said Dr. Cox.
Marissa handed the receiver back to Dr. Navarre, who hung up. “Let me bring you up to date,” he said, switching to a standard medical monotone as he pulled some three-by-five cards from his pocket. “We have seven cases of an undiagnosed, but obviously severe, febrile illness characterized by prostration and multi-system involvement. The first patient to be hospitalized happens to be one of the cofounders of the clinic, Dr. Richter himself. The next, a woman from the medical records department.” Dr. Navarre began placing his three-by-five cards on the table. Each one represented a patient. He organized them in the order in which the cases had presented themselves.
Discreetly snapping open her briefcase without allowing Dr. Navarre to see what it contained, Marissa extracted her note pad and a pencil. Her mind raced back to the courses she’d recently completed, remembering that she needed to break the information down into understandable categories. First the illness: Was it really something new? Did a problem really exist? That was the province of the simple 2 x 2 table and some rudimentary statistics. Marissa knew she had to characterize the illness even if she couldn’t make a specific diagnosis. The next step would be to determine host factors of the victims, such as age, sex, health, eating habits, hobbies, etc., then to
determine time, place and circumstances in which each patient displayed initial symptoms, in order to learn what elements of commonality existed. Then there would be the question of transmission of the illness, which might lead to the infectious agent. Finally, the host or reservoir would have to be erradicated. It sounded so easy, but Marissa knew it would be a difficult problem, even for someone as experienced as Dubchek.
Marissa wiped her moist hand on her skirt, then picked up her pencil once more. “So,” she said, staring at the blank page. “Since no diagnosis has been made, what’s being considered?”
“Everything,” said Dr. Navarre.
“Influenza?” asked Marissa, hoping she wasn’t sounding overly simplistic.
“Not likely,” said Dr. Navarre. “The patients have respiratory symptoms but they do not predominate. Besides, serological testing has been negative for influenza virus in all seven patients. We don’t know what they have, but it is not influenza.”
“Any ideas?” asked Marissa.
“Mostly negatives,” said Dr. Navarre. “Everything we’ve tested has been negative: blood cultures, urine cultures, sputum cultures, stool cultures, even cerebrospinal fluid cultures. We thought about malaria and actually treated for it, though the blood smears were negative for the parasites. We even treated for typhoid, with either tetracycline or chloramphenicol, despite the negative cultures. But, just like with the antimalarials, there was no effect whatsoever. The patients are all going downhill no matter what we do.”
“You must have some kind of differential diagnosis,” said Marissa. “Of course,” responded Dr. Navarre. “We’ve had a number of infectious disease consults. The consensus is that it is a viral problem, although leptospirosis is still a weak contender.” Dr. Navarre searched through his index cards, then held one up. “Ah, here are the current differential diagnoses: leptospirosis, as I mentioned; yellow fever; dengue; mononucleosis; or, just to cover the bases, some other enteroviral, arboviral or adenoviral infection. Needless to say, we’ve made about as much progress in the diagnostic realm as the therapeutic.”
“How long has Dr. Richter been hospitalized?” asked Marissa.
“This is his fifth day. I think you should see the patients to have an idea of what we are dealing with.” Dr. Navarre stood up without waiting for Marissa’s response. She found she had to trot to keep up with him. They went through swinging doors and entered the hospital proper. Nervous as she was, Marissa could not help being impressed by the luxurious carpeting and almost hotellike decor.
She got on the elevator behind Dr. Navarre, who introduced her to an anesthesiologist. Marissa returned the man’s greeting, but her thoughts were elsewhere. She was certain that her seeing the patients at that moment was not going to accomplish anything except to make her feel “exposed.” This issue had not occurred to her while taking the introductory course back in Atlanta. Suddenly it seemed like a big problem. Yet what could she say?
They arrived at the nurses’ station on the fifth floor. Dr. Navarre took the time to introduce Marissa to the night staff, who were making their initial preparations to change shifts.
“All seven patients are on this floor,” said Dr. Navarre. “It has some of our most experienced personnel. The two in critical condition are in separate cubicles in the medical intensive-care unit just across the hall. The rest are in private rooms. Here are the charts.” With an open palm, he thumped a pile stacked on the corner of the counter top. “I assume you’d like to see Dr. Richter first.” Dr. Navarre handed Richter’s chart to Marissa.
The first thing she looked at was the “vital-sign” sheet. Beginning his fifth hospital day, she noticed that the doctor’s blood pressure was falling and his temperature was rising. Not a good omen. Rapidly she perused the chart. She knew that she’d have to go over it carefully later. But even a cursory glance convinced her that the workup had been superb, better than she could have done herself. The laboratory work had been exhaustive. Again she wondered what in God’s name she was doing there pretending to be an authority.
Going back to the beginning of the chart, Marissa read the section entitled “history of the present illness.” Something jumped out at her right away. Six weeks previous to the onset of symptoms Dr. Richter had attended an ophthalmological convention in Nairobi, Kenya.
She read on, her interest piqued. One week prior to his illness, Dr. Richter had attended an eyelid surgery conference in San Diego. Two days prior to admission he’d been bitten by a Cercopitheceus aethiops, whatever the hell that was. She showed it to Dr. Navarre.
“It’s a type of monkey,” said Dr. Navarre. “Dr. Richter always has a few of them on hand for his ocular herpes research.”
Marissa nodded. She glanced again at the laboratory values and noted that the patient had a low white count, a low ESR and low thrombocytes. Other lab values indicated liver and kidney malfunction. Even the EKG showed mild abnormalities. This guy was virulently sick.
Marissa laid the chart down on the counter.
“Ready?” questioned Dr. Navarre.
Although Marissa nodded that she was, she would have preferred to put off confronting the patients. She had no delusions of grandeur that she would uncover some heretofore missed, but significant, physical sign, and thereby solve the mystery. Her seeing the patients at that point was pure theater and, unfortunately, risky business. She followed Dr. Navarre reluctantly.
They entered the intensive-care unit, with its familiar backdrop of complicated electronic machinery. The patients were immobile victims, secured with tangles of wires and plastic tubing. There was the smell of alcohol, the sound of respirators and cardiac monitors. There was also the usual high level of nursing activity.
“We’ve isolated Dr. Richter in this side room,” said Dr. Navarre, stopping at the closed doorway. To the left of the door was a window, and inside the room Marissa could make out the patient. Like the others in the unit, he was stretched out beneath a canopy of intravenous bottles. Behind him was a cathode-ray tube with a continuous EKG tracing flashing across its screen.
“I think you’d better put on a mask and gown,” said Dr. Navarre. “We’re observing isolation precautions on all the patients for obvious reasons.”
“By all means,” said Marissa, trying not to sound too eager. If she had her way, she’d climb into a plastic bubble. She slipped on the gown and helped herself to a hat, mask, booties, and even rubber gloves. Dr. Navarre did likewise.
Unaware she was doing it, Marissa breathed shallowly as she looked down at the patient, who, in irreverent vernacular, looked as if he was about to “check out.” His color was ashen, his eyes sunken, his skin slack. There was a bruise over his right cheekbone; his lips were dry, and dried blood was caked on his front teeth.
As Marissa stared down at the stricken man, she didn’t know what to do; yet she self-consciously felt obliged to do something, with Dr. Navarre hanging over her, watching her every move. “How do you feel?” asked Marissa. She knew it was a stupid, self-evident question the moment it escaped from her lips. Nonetheless Richter’s eyes fluttered open. Marissa noticed some hemorrhages in the whites.
“Not good,” admitted Dr. Richter, his voice a hoarse whisper.
“Is it true you were in Africa a month ago?” she asked. She had to lean over to hear the man, and her heart went out to him.
“Six weeks ago,” said Dr. Richter.
“Did you come in contact with any animals?” asked Marissa.
“No,” managed Dr. Richter after a pause. “I saw a lot but didn’t handle any.”
“Did you attend anyone who was ill?”