Outbreak

by Robin Cook

  “It’s too long ago to be significant,” Dubchek said dogmatically. “That conference was over six weeks ago.”

  “But it appears to be the only association between the two doctors,” protested Marissa. “I think I should follow up on it.”

  “Suit yourself,” said Dubchek. “Meanwhile, I’d like you to go down to pathology and make sure they take every precaution when they post Zabriski this morning. And tell them that we want quick-frozen samples of liver, heart, brain and spleen for viral isolation.”

  “What about kidney?” interjected Layne.

  “Yeah, kidney, too,” said Dubchek.

  Marissa went off feeling like an errand girl. She wondered if she would ever regain Dubchek’s respect, then remembering why she’d lost it, her depression was wiped out by a surge of anger.

  In pathology, a busy place at that time of day, Marissa was directed to the autopsy rooms, where she knew she’d find Dr. Rand. Remembering his pompous, overbearing manner, she was not looking forward to talking with him.

  The autopsy rooms were constructed of white tile and gleaming stainless steel. There was a pervading aroma of formalin that made Marissa’s eyes water. One of the technicians told her that Zabriski’s post was scheduled for room three. “If you intend to go, you have to suit up. It’s a dirty case.”

  With her general fear of catching Ebola, Marissa was more than happy to comply. When she entered the room, she found Dr. Rand just about to begin. He looked up from the table of horrific tools. Dr. Zabriski’s body was still enclosed in a large, clear plastic bag. His body was a pasty white on the top, a livid purple on the bottom.

  “Hi!” said Marissa brightly. She decided that she might as well be cheerful. Receiving no answer, she conveyed the CDC’s requests to the pathologist, who agreed to supply the samples. Marissa then suggested the use of goggles. “A number of cases both here and in L.A. were apparently infected through the conjunctival membrane,” she explained.

  Dr. Rand grunted, then disappeared. When he returned he was wearing a pair of plastic goggles. Without saying anything he handed a pair to Marissa.

  “One other thing,” Marissa added. “The CDC recommends avoiding power saws on this kind of case because they cause significant aerosol formation.”

  “I was not planning to use any power tools,” said Dr. Rand. “Although you may find this surprising, I have handled infectious cases during my career.”

  “Then I suppose I don’t have to warn you about not cutting your fingers,” said Marissa. “A pathologist died of viral hemorrhagic fever after doing just that.”

  “I recall,” said Dr. Rand. “Lassa Fever. Are you about to favor us with any further suggestions?”

  “No,” said Marissa. The pathologist cut into the plastic bag and exposed Zabriski’s body to the air. Marissa debated whether she should go or stay. Indecision resulted in inaction; she stayed.

  Speaking into an overhead microphone activated by a foot pedal, Dr. Rand began his description of the external markings of the body. His voice had assumed that peculiar monotone Marissa remembered from her medical school days. She was startled back to the present when she heard Rand describe a sutured scalp laceration. That was something new. It hadn’t been in the chart, nor had the cut on the right elbow or the circular bruise on the right thigh, a bruise about the size of a quarter.

  “Did these abrasions happen before or after death?”

  “Before,” he answered, making no attempt to conceal his irritation at the interruption.

  “How old do you think they are?” said Marissa, ignoring his tone. She bent over to look at them more carefully.

  “About a week old, I’d say,” Dr. Rand replied. “Give or take a couple of days. We’d be able to tell if we did microscopic sections. However, in view of the patient’s condition, I hardly think they are important. Now, if you don’t mind, I’d like to get back to work.”

  Forced to step back, Marissa thought about this evidence of trauma. There was probably some simple explanation; perhaps Dr. Zabriski had fallen playing tennis. What bothered Marissa was that the abrasion and the laceration were not mentioned on the man’s chart. Where Marissa had trained, every physical finding went into the record.

  As soon as Rand had finished and Marissa had seen that the tissue samples were correctly done, she decided to track down the cause of the injuries.

  Using the phone in pathology, Marissa tried Zabriski’s secretary, Judith. She let the phone ring twenty times. No answer. Reluctant to bother Mrs. Zabriski, Marissa thought about looking for Dr. Taboso, but instead decided to check Dr. Zabriski’s office, realizing it had to be right there in the hospital. She walked over and found Judith back at her desk.

  Judith was a frail young woman in her mid-twenties. Mascara smudged her cheeks; Marissa could tell that she’d been crying. But she was more than sad; she was also terrified.

  “Mrs. Zabriski is sick,” she blurted out as soon as Marissa introduced herself. “I talked with her a little while ago. She’s downstairs in the emergency room but she is going to be admitted to the hospital. They think she has the same thing that her husband had. My God, am I going to get it too? What are the symptoms?”

  With some difficulty, Marissa calmed the woman enough to explain that in the L.A. outbreak the doctor’s secretary had not come down with the illness.

  “I’m still getting out of here,” said Judith, opening a side drawer of her desk and taking out a sweater. She tossed it into a cardboard box. She’d obviously been packing. “And I’m not the only one who wants to go,” she added. “I’ve talked with a number of the staff and they are leaving, too.”

  “I understand how you feel,” said Marissa. She wondered if the entire hospital would have to be quarantined. At the Richter Clinic, it had been a logistical nightmare.

  “I came here to ask you a question,” said Marissa.

  “So ask,” said Judith. She continued to empty her desk drawers.

  “Dr. Zabriski had some abrasions and a cut on his head, as if he’d fallen. Do you know anything about that?”

  “That was nothing,” said Judith, making a gesture of dismissal with her hand. “He was mugged about a week ago, in a local mall while he was shopping for a birthday gift for his wife. He lost his wallet and his gold Rolex. I think they hit him on the head.”

  So much for the mysterious question of trauma, thought Marissa. For a few minutes she stood watching Judith throw her things into the box, trying to think if she had any further questions. She couldn’t think of any just then, so she said good-bye, then left, heading for the isolation ward. In many ways she felt as scared as Judith did.

  The isolation ward had lost its previous tranquility. With all the new patients, it was fully staffed with overworked nurses. She found Dr. Layne writing in several of the charts.

  “Welcome to Bedlam,” he said. “We’ve got five more admissions, including Mrs. Zabriski.”

  “So I’ve heard,” said Marissa, sitting down next to Dr. Layne. If only Dubchek would treat her as he did: like a colleague.

  “Tad Schockley called earlier. It is Ebola.”

  A shiver ran down Marissa’s spine.

  “We’re expecting the State Commissioner of Health to arrive any minute to impose quarantine,” continued Dr. Layne. “Seems that a number of hospital personnel are abandoning the place: nurses, technicians, even some doctors. Dr. Taboso had a hell of a time staffing this ward. Have you seen the local paper?”

  Marissa shook her head, indicating that she had not. She was tempted to say that she didn’t want to stay either, if it meant being exposed.

  “The headline is ‘Plague Returns!’ ” Dr. Layne made an expression of disgust. “The media can be so goddamned irresponsible. Dubchek doesn’t want anyone to talk with the press. He wants all questions directed to him.”

  The sound of the patient-elevator doors opening caught Marissa’s attention. She watched as a gurney emerged, covered by a clear plastic isolation tent. As it went by
, Marissa recognized Mrs. Zabriski. She shivered again, wondering if the local paper really had been exaggerating in their headline.

  6

  April 10

  MARISSA TOOK ANOTHER FORKFUL of the kind of dessert that she allowed herself only on rare occasions. It was her second night back in Atlanta, and Ralph had taken her to an intimate French restaurant. After five weeks with little sleep, gulping down meals in a hospital cafeteria, the gourmet meal had been a true delight. She noticed that, not having had a drink since she’d left Atlanta, the wine had gone right to her head. She knew she was being very talkative, but Ralph seemed content to sit back and listen.

  Winding down, Marissa apologized for chattering on about her work, pointing to her empty glass as the excuse.

  “No need to apologize,” Ralph insisted. “I could listen all night. I’m fascinated by what you have accomplished, both in L.A. and in St. Louis.”

  “But I’ve filled you in while I was away,” protested Marissa, referring to their frequent phone conversations. While she’d been in St. Louis, Marissa had gotten into the habit of calling every few days. Talking with Ralph had provided a sounding board for her theories as well as a way to relieve her frustration at Dubchek’s continued insistence on ignoring her. In both cases, Ralph had been understanding and supportive.

  “I wish you’d tell me more about the community reaction,” he said. “How did the administrators and medical staff of the hospital try to control the panic, considering that this time there were thirty-seven deaths?”

  Taking him at his word, Marissa tried to describe the turmoil at the St. Louis hospital. The staff and patients were furious at the enforced quarantine, and Dr. Taboso had sadly told her he expected the hospital to close when it was lifted.

  “You know, I’m still worried abut getting sick myself,” admitted Marissa with a self-conscious laugh. “Every time I get a headache I think ‘this is it.’ And though we still have no idea where the virus came from, Dubchek’s position is that the virus reservoir is somehow associated with medical personnel, which doesn’t make me any more comfortable.”

  “Do you believe it?” asked Ralph.

  Marissa laughed. “I’m supposed to,” she said. “And if it is true, then you should consider yourself particularly at risk. Both index cases were ophthalmologists.”

  “Don’t say that,” laughed Ralph. “I’m superstitious.”

  Marissa leaned back as the waiter served a second round of coffee. It tasted wonderful, but she suspected she’d be sorry later on when she tried to sleep.

  After the waiter left with the dessert dishes, Marissa continued: “If Dubchek’s position is correct, then somehow both eye doctors came into contact with the mysterious reservoir. I’ve puzzled over this for weeks without coming up with a single explanation. Dr. Richter came in contact with monkeys; in fact he’d been bitten a week before he became ill, and monkeys have been associated with a related virus called Marburg. But Dr. Zabriski had no contact with any animals at all.”

  “I thought you told me that Dr. Richter had been to Africa,” said Ralph. “It seems to me that is the crucial fact. After all, Africa is where this virus is endemic.”

  “True,” said Marissa. “But the time frame is all wrong. His incubation period would have been six weeks, when all the other cases averaged only two to five days. Then consider the problem of relating the two outbreaks. Dr. Zabriski hadn’t been to Africa, but the only point of connection was that the two doctors attended the same medical conference in San Diego. And again, that was six weeks before Dr. Zabriski got sick. It’s crazy.” Marissa waved her hand as if she were giving up.

  “At least be happy you controlled the outbreaks as well as you did. I understand that it was worse when this virus appeared in Africa.”

  “That’s true,” agreed Marissa. “In the Zaire outbreak in 1976, whose index case may have been an American college student, there were three hundred eighteen cases and two hundred eighty deaths.”

  “There you go,” said Ralph, feeling that the statistics should cheer Marissa. He folded his napkin and put it on the table. “How about stopping at my house for an after-dinner drink?”

  Marissa looked at Ralph, amazed at how comfortable she’d become with him. The surprising thing was that the relationship had developed on the telephone. “An after-dinner drink sounds fine,” she said with a smile.

  On the way out of the restaurant, Marissa took Ralph’s arm. When they got to his car, he opened the door for her. She thought that she could get used to such treatment.

  Ralph was proud of his car. It was obvious in the loving way he touched the instruments and the steering wheel. The car was a new 300 SDL Mercedes. Marissa appreciated its luxuriousness as she settled back in the leather seat, but cars had never meant much to her. She also couldn’t understand why people bought diesels since they had an uncomfortable rattle when they started and idled. “They are economical,” said Ralph. Marissa looked around at the appointments. She marveled that someone could delude himself that an expensive Mercedes was economical.

  They didn’t speak for a while, and Marissa wondered if going to Ralph’s house at that time of night was a good idea. But she trusted Ralph and was willing to let their relationship develop a little further. She turned to look at him in the half-light. He had a strong profile, with a prominent nose like her father’s.

  After they had settled on the couch in the parlor, with brandy snifters in hand, Marissa mentioned something she had been afraid to point out to Dubchek in his current patronizing mood. “There is one thing about the two index cases that I find curious. Both men were mugged just a few days before they got sick.” Marissa waited for a response.

  “Very suspicious,” said Ralph with a wink. “Are you suggesting that there is an ‘Ebola Mary’ who robs people and spreads the disease?”

  Marissa laughed. “I know it sounds stupid. That’s why I haven’t said anything to anyone else.”

  “But you have to think of everything,” added Ralph. “The old medical-school training that taught you to ask everything, including what the maternal great-grandfather did for a living in the old country.”

  Deliberately, Marissa switched the conversation to Ralph’s work and his house, his two favorite subjects. As the time passed, she noted that he did not make any moves toward her. She wondered if it were something about herself, like the fact that she’d been exposed to Ebola. Then, to make matters worse, he invited her to spend the night in the guest room.

  Marissa was insulted. Perhaps just as insulted as if he’d tried to drag her dress over her head the moment they walked in the front door. She told him thank you, but she did not want to spend the night in his guest room; she wanted to spend the night in her own house with her dog. The last part was meant to be an affront, but it sailed over Ralph’s head. He just kept on talking about redecorating plans he had for the first floor of the house, now that he’d lived there long enough to know what he wanted.

  In truth, Marissa did not know what she would have done if Ralph had made any physical advances. He was a good friend, but she still didn’t find him romantically attractive. In that respect, she thought Dubchek’s looks distinctly more exciting.

  Thinking of Cyrill reminded her of something. “How do you and Dr. Dubchek know each other?”

  “I met him when he addressed the ophthalmology residents at the University Hospital,” said Ralph. “Some of the rare viruses like Ebola and even the AIDS virus have been localized in tears and the aqueous humor. Some of them even cause anterior uveitis.”

  “Oh,” said Marissa, nodding as if she understood. Actually she had no idea what anterior uveitis was, but she decided it was as good a point as any to ask Ralph to drive her home.

  Over the next few days, Marissa adapted to a more normal life, although every time the phone rang, she half expected to be called out for another Ebola disaster. Remembering her resolve, she did pack a suitcase and kept it open in her closet, ready for her to toss in her
cosmetics case. She could be out of her house in a matter of minutes, if the need arose.

  At work, things were looking up. Tad helped her perfect her viral laboratory skills and worked with her to write up a research proposal on Ebola. Unable to come up with a working hypothesis for a possible reservoir for Ebola, Marissa concentrated instead on the issue of transmission. From the enormous amount of data that she’d amassed in L.A. and St. Louis, she had constructed elaborate case maps to show the spread of the illness from one person to another. At the same time, she’d compiled detailed profiles on the people who had been primary contacts but who had not come down with the disease. As Dr. Layne had suggested, close personal contact was needed, presumably viral contact with a mucous membrane, though, unlike AIDS, sexual transmission had only been a factor between Dr. Richter and the medical secretary and Dr. Zabriski and his wife. Given the fact that hemorrhagic fever could spread between strangers who shared a towel, or by the most casual close touch, Ebola made the AIDS scare seem like a tempest in a teapot.

  What Marissa wanted to do was to validate her hypothesis by using guinea pigs. Of course such work required the use of the maximum containment lab, and she still had not obtained permission.

  “Amazing!” exclaimed Tad, one afternoon when Marissa demonstrated a technique she’d devised to salvage bacteria-contaminated viral cultures. “I can’t imagine Dubchek turning down your proposal now.”

  “I can,” answered Marissa. She debated telling Tad about what had happened in the L.A. hotel, but once again she decided not to do so. It wouldn’t accomplish anything and might cause problems in Tad’s relationship with Cyrill.

  She followed her friend into his office. As they relaxed over coffee, Marissa said, “Tad, you told me when we went into the maximum containment lab that there were all sorts of viruses stored in there, including Ebola.”