by A. G. Riddle
“I understand. Believe me, I’m not going to hurt you. I’m a victim too.”
A pause. Then he spoke with hesitation. “Where? When?”
Desmond considered a few options. He was exhausted, and he needed to prepare for the meeting. “Tomorrow at noon. The Brandenburg Gate. Stand in the tourist area, holding a sign that says Looking Glass Tours, prices negotiable. Wear a navy peacoat, blue jeans, and a black hat with nothing on it.”
“You want to meet in public?”
“It’s safer that way. Leave your phone at home. Come alone. Unarmed.”
He snorted, sounding disgusted. “Says the man wanted for murder.”
“Being wanted for murder doesn’t mean I’m guilty of murder. You want answers, meet me tomorrow.”
“Fine.”
When the line went dead, Desmond began planning the meeting: every aspect, every possible contingency. If he played his cards right, he might soon know what was going on.
Chapter 10
That night, Dr. Elim Kibet made his rounds at Mandera Referral Hospital, then retreated to his office, where he took off his worn white coat and began writing an email to the Kenyan Ministry of Public Health:
To whom it may concern:
The situation here has deteriorated. I again implore you to send help with all possible haste.
The American male, who arrived here this morning and presented with symptoms of an as-yet-unidentified hemorrhagic fever, has died. We are ill equipped to perform an autopsy or handle his remains. I have sealed his room and barred anyone from entering.
His passing distressed his companion greatly. More concerning, the young man, who is named Lucas Turner, has developed a fever, most recently recorded at 102. I fear it will continue to climb and that he will soon develop symptoms similar to his now-deceased companion. If so, his fate may well be the same.
I have endeavored to keep detailed notes on his progression and have instructed the staff to take pictures on the hour. Frankly, documenting the disease is perhaps the only useful thing I can do. I have also dedicated much of my time to recording the details of the two Americans’ travel, including where they visited and whom they talked to. Additionally, I have asked Lucas about his friend’s history of symptoms. I believe it will prove quite helpful to epidemiologists investigating this outbreak. I will forward my notes as I have time.
The British patient, who was brought in from the airport, remains in critical condition. I’m not optimistic that he will survive the night.
Lastly, we face a new crisis here at MCRH: personnel. I arrived this morning to find that over half of the hospital’s staff did not report for work. I cannot blame them. As I have said, we are ill equipped to deal with these patients. I have instructed nurses to wear gowns, boot covers, facemasks, goggles, and double gloves, but I fear these measures may prove inadequate, and our supplies of protective equipment will very soon run out.
I ask you again:
Outside his office, a nurse yelled, “Dr. Kibet!”
Seconds later, the door swung open. The man was bent forward, his hands on his knees, catching his breath. “More infected,” he said between pants.
Elim grabbed his coat, and the two men raced down the corridor to triage. Elim stopped in his tracks, taking in the horror.
Ten people, all local villagers, all very sick. Sweat and vomit stains covered their clothes. A few stared with yellowed, bloodshot eyes.
A nurse drew a thermometer from a man’s mouth and turned to Elim. “A hundred and five.”
It had spread to the villages. Elim wondered if help would be too late—for all of them.
Chapter 11
When the Air Force transport reached cruising altitude, Peyton stretched out across several chairs, strapped herself in, and slept.
She had gotten only four hours of sleep the night before and had been going as hard as she could all day. Still, she set her alarm for only thirty minutes later. She wanted to be fresh but not groggy for what came next.
Perhaps the most valuable skill she’d acquired while working at the CDC was the ability to sleep nearly anywhere. It had taken her years to master the practice. For her, thinking was the greatest enemy of sleep. When she was battling an outbreak, her mind never stopped working; thinking became a compulsion. But during her second year of fieldwork, she had learned a sleep technique she’d used ever since. When she needed to rest, she closed her eyes, refused to let her mind think, and instead focused on her breathing. She first forced herself to draw her breaths into her belly, allowing her abdomen to expand, not her chest. With each exhalation, she focused on the tip of her nose, where the breath touched as it flowed out of her, and counted the breaths. She rarely got past forty.
When her phone alarm buzzed in her pocket, she rose, stretched, and did a few light exercises.
She had been given the option of flying on the air ambulance instead of the Air Force transport. She would have been more comfortable there, but she’d wanted to remain with her team. To Peyton, it was a matter of principle. Besides, they had work to do. She had insisted that three of the older CDC employees take the seats on the air ambulance. They would be working in Nairobi, in support positions, and all three had thanked her for the more comfortable accommodations.
Elliott had chosen the Air Force transport as well. It had a large compartment for cargo and a separate area for passengers. The passenger section had twelve rows, each with five seats in the center, plus a single row of seats lining each of the right and left walls. At the head of the compartment were two narrow openings beside a wide wall that held a whiteboard.
Peyton imagined that the whiteboard was routinely used to brief military personnel and hammer out mission details. She was about to do the same. In fact, to an outside observer, the scene might have looked like a US Navy mission briefing.
Her audience included men and women dressed in tan service khakis identical to the uniforms worn by the US Navy, with similar rank insignias. Her troops, however, were not naval officers. They were officers in another uniformed service, one every bit as important.
Peyton was a CDC employee, but she was also a Commissioned Corps officer of the US Public Health Service. The Commissioned Corps was an elite team of highly skilled health professionals and one of the United States’ seven uniformed services (the other six being the Army, Navy, Air Force, Marines, Coast Guard, and National Oceanic and Atmospheric Administration Commissioned Corps). Over six thousand men and women served in the Public Health Service Commissioned Corps, and they wore uniforms similar to the US Navy’s: service dress blues, summer whites, and service khakis. Commissioned Corps officers held the same ranks as the Navy and Coast Guard: ensign to admiral.
Commissioned Corps officers served at the EPA, FDA, DOD, NIH, USDA, Coast Guard, CDC, and many other organizations. They were often the first responders during national disasters, and had deployed in response to hurricanes, earthquakes, and outbreaks. In 2001, over one thousand PHS officers deployed to New York City after the 9/11 attacks. In 2005, in the aftermath of three hurricanes—Katrina, Rita, and Wilma—more than two thousand PHS officers deployed to set up field hospitals and assist victims.
Over eight hundred Commissioned Corps officers worked full-time at the CDC. Visitors often mistook them for Navy officers.
Peyton held the rank of full commander in the Commissioned Corps. Elliott held the rank of rear admiral. Of the 160 EIS officers, 102 were Commissioned Corps officers.
The Corps was also well represented in the group sitting before Peyton: of the 63 men and women present, 51 were Commissioned Corps officers. Like Peyton, they dressed in service khakis, the PHSCC insignia on their left lapel, their rank insignia on their right.
Peyton pulled her shoulder-length black hair into a ponytail and smoothed out her rumpled uniform. She straightened the silver oak leaf that designated her rank and walked to the whiteboard.
Sixty-three faces focused on her. She saw nervousness and excitement and, above all el
se, trust—absolute trust in her ability to guide them through the coming deployment, to keep them safe, and to teach them what they needed to know. She felt the weight of their trust and the burden of her duty. She was an epidemiologist, but she considered her most important job to be that of a teacher. As an EIS instructor, it was her job to prepare her students for whatever they might encounter after their fellowship. The men and women who sat before her were the next generation of public health leaders. And one day, one of them would likely be standing where she was: leading a future CDC mission, or a state or city health department, or conducting vital research for the National Institutes of Health.
Being a teacher was a role she relished, because it was so important, and because along her own career path she herself had been lucky enough to have good teachers who cared. Fifteen years ago, Peyton had been sitting in a crowd like this one. She had been one of these faces, and it had been Elliott standing before them, giving a similar talk. She remembered how nervous she was during her first deployment. She still felt a hint of those nerves. Sometimes she wondered if there was a little excitement mixed in—the thrill of the mission, the stakes, the chase to find the origin of the outbreak and stop it before a catastrophe occurred. She had come to live for days like these. Being in the middle of a crisis almost felt more natural to her than the downtime she spent in Atlanta.
Since it was a long flight and they would need to adjust to the eight-hour time difference between eastern Kenya and Atlanta, Peyton had decided to divide her briefing into two parts. The first would be background—information many of the full-time, seasoned CDC personnel knew by heart. Many of the EIS officers did too, but a refresher was prudent, and it was a great way to break the ice. This was the first foreign deployment for many of the officers, and Peyton knew they were nervous. Going over what they already knew would give them a boost of confidence.
She grabbed a blue marker from the whiteboard’s tray. “Okay, let’s get started. As you know from the preliminary briefing, we’ll be splitting up in Nairobi. Eleven of you will be assisting with operations there; the remainder will join me in Mandera and will likely travel to the surrounding areas. However, I want each of you to be versed on our PPE protocol for the deployment, and I want to share some basic background information. We’ll cover mission-specific directives once we get closer to landing.”
She quickly covered their PPE, which included gowns, coveralls, hoods, goggles, boot covers, gloves, and other items used to protect against infectious material.
“There’s a chance that each of you will come into contact with the pathogen in some way. Those of you in Nairobi may be called into the field. First, know that it will be hot inside the suits. Kenya is located in a tropical zone. Nairobi is just eighty-eight miles from the equator. Even though it’s November, the midday sun in Kenya will cook you. You’ll be sweating before you put your suit on, and you’ll sweat even more while wearing it.
“Second, you’ll likely be unnerved by what you see. Some of us never get used to the human suffering we encounter during these deployments. There’s nothing wrong with that. You’re going to witness people living in poverty and circumstances you may have never seen before. If you feel overwhelmed, it’s okay to excuse yourself. Just let a team member know, then walk away and take deep breaths. Whatever you do, do not take your suit off. Inspecting and donning your suit is important, but being careful while doffing it is even more important. After you’ve had contact with patients, you may have virus particles and bacteria on the outside of your suit, hood, goggles, gloves, and boots. If you just rip any part of your PPE off, you’re putting your life at risk. When it comes to removing your suit: take—your—time. It won’t be easy; one hour is about all anyone can stand in the suits in this kind of heat, and by the end of that hour, you’ll be dying to get free. But again, take your time. Your life depends on it.
“Okay, what’s our deployment goal here? Anybody?”
The EIS agents, most in their late twenties or early thirties, sat near the front. The permanent CDC staff on the mission were a bit older, and most had deployed for a dozen outbreaks before. They sat toward the back and kept quiet during the Q&A, giving the EIS officers the opportunity to answer and learn.
In the second row, a woman named Hannah Watson answered. Her strawberry-blond hair was tied in a ponytail, and like Peyton, she wore Commissioned Corps service khakis.
“Containment and treatment.”
“Good.” Peyton wrote the words in large block letters on the whiteboard. “What else?”
“Identification,” Millen Thomas called out. He was a veterinarian of Indian descent, sitting several rows behind Hannah.
Peyton nodded as she wrote the word on the board. “Yes, it would be nice, at some point, to know exactly what we’re dealing with here. What else?”
An EIS officer in plain clothes called out, “Capacity building.”
“Very good. We are here to identify, treat, and contain this disease, but we’re also here to help the Kenyans develop their own capacity to stop outbreaks. The CDC has poured millions of dollars into Kenya with the hope of developing a disease detection and surveillance system as well as native capability to respond to outbreaks.
“In the battle against pandemics,” Peyton continued, “we have only one hope, and that’s to stop outbreaks where they start. To do that, we need to enable the Kenyans. For those of us in the field, it means training the Kenyan field epidemiologists. In Nairobi, that means giving the staff in the Ministry of Health and their EOC the support and training they need.
“Okay.” Peyton turned back to the board and circled the word Identification. “How do we identify?”
“Lab tests,” a black-haired girl called out.
“Yes. We have a field test for Ebola: the ReEBOV Antigen Rapid Test Kit. ReEBOV will give us a result in about fifteen minutes. Accuracy is 92% for those infected and about 85% for those negative. What else?”
“Symptoms. Disease progression,” a black man in the front row said.
“Correct. If we can establish a consistent pattern of symptoms, we can make a pretty good guess about what we’re dealing with. We’ll be taking patient histories from multiple locations. In Nairobi, your job will be to take all those data points and establish a clear pattern. We’re looking for trends and commonalities. Now—assuming this is Ebola, what are the symptoms?”
Voices across the group called out:
“High fever.”
“Severe headache.”
“Diarrhea.”
“Vomiting.”
“Stomach pain.”
“Fatigue and weakness.”
“Bleeding.”
“Bruising.”
Peyton wrote quickly. “Good. The patients at Mandera presented with most of these symptoms. The physician there also reported seeing a rash. So we may or may not be dealing with Ebola. It may be a completely new filovirus or arenavirus. We know the disease we’re facing is deadly and that it has sickened people in what we believe are two different locations. It takes a human anywhere from two to twenty days to develop Ebola symptoms. On average, infected individuals develop symptoms eight to ten days after contact with the virus. All right. Again, if this is Ebola, how do we treat it?”
“We don’t,” said a white physician in the third row.
“ZMapp,” a redheaded girl said.
“You’re actually both right. There is no FDA-approved treatment for Ebola. There is no vaccine. If a patient breaks with the disease, we simply give them fluids, electrolytes, and treat any secondary infections. In short, the patient is on their own. The hope is that their immune system fights and defeats the virus. About half do; the average Ebola case fatality rate is fifty percent.
“It’s also important to note that there are five known strains of Ebola: Zaire, Ivory Coast, Sudan, Bundibugyo, and Reston. Reston ebolavirus is the only strain that’s airborne. It’s named Reston because it was discovered in Reston, Virginia, only miles from the White
House. It is quite possibly the greatest piece of luck in human history that the Reston strain only causes disease in non-human primates. In fact, during the Reston outbreak—which occurred at a primate facility—several researchers were infected. Luckily, all remained asymptomatic. If Ebola Reston had been deadly for humans, there would be a whole lot fewer of us around today. The other four strains of Ebola are among the most deadly pathogens on the planet. Zaire ebolavirus is the worst, killing up to ninety percent of those it infects.
“ZMapp is the only therapy that has proven effective in treating Ebola. It did very well in primate trials. During the West African Ebola outbreak in 2014, we treated seven Americans with ZMapp and an RNA interference drug called TKM-Ebola. Unfortunately, two of those patients died, but five survivors out of seven is still beating the usual odds. We have some ZMapp with us in the cargo hold, but it’s a very small quantity, and I want to stress again that it is not FDA-approved and has had mixed results in humans.
“Can anybody tell me what type of therapy ZMapp is?”
A voice called out, “A monoclonal antibody.”
“Correct. ZMapp is a monoclonal antibody or mab. In fact, it has three mabs. They’re grown in tobacco plants, strangely enough, and they bind the Ebola protein as if they were antibodies made by the patient’s own immune system. So, how might that impact future treatments? Anybody?”
Peyton paused and looked around the group. When no one answered, she continued. “Survivors. Studying the antibodies that survivors produce could offer clues about new therapies and ways to fight the virus. So it’s incredibly important that we document those survivors. In fact, there’s research in progress right now that’s doing just that: studying the immune systems of people who survived a Marburg outbreak years ago. In a worst-case scenario, we could also try using convalescent blood or plasma from survivors to treat critical personnel in Kenya.