The Coming Plague

by Laurie Garrett

  On October 18, six weeks after the Yambuku epidemic began, the core of what would that day be dubbed the International Commission arrived. Loaded down with enormous crates of sophisticated laboratory equipment, a plastic isolator for research, state-of-the-art microscopes and protective gear came the Americans: Karl Johnson and Joel Breman of the CDC’s Special Pathogens Branch. Still in her maximum-security Atlanta laboratory, Patricia Webb was steaming mad. Just days before her planned departure, CDC director David Sencer had decided the job was “too big,” and leadership of the mission was awarded not to the woman, but to her husband.

  The Machupo legends had preceded Johnson to Kinshasa, and Sureau’s admiration for the man who discovered and survived Bolivian hemorrhagic fever was undisguised. Now a middle-aged veteran of dozens of CDC investigations, Johnson carried himself with a reasoned calm that inspired confidence in the men around him. He would be the foreman for an often adventuristic bunch of disease cowboys. Johnson, Breman, and Sureau became instant friends, and everyone, including the Zairois, deferred to Johnson’s leadership.

  By the end of the day the core of the International Commission was in place, and its first meeting convened (tensions eased by ample quantities of French wine) at five o’clock in the evening, October 18, chaired by Minister Ngwété. Present were six Zairois, including Omombo, whose twenty-four-hour visit to the Yambuku Mission had dramatically raised levels of anxiety in Kinshasa government circles. Representing WHO were Sureau, smallpox expert René Collas, and two Zaire-based European physicians. The five-man Belgian contingent included Stefan Pattyn and Peter Piot. One South African (Isaacson) and one official French representative (Gilbert Raffier) were present. And Americans Johnson, Close, and Breman were joined by Dr. John Kennedy of the U.S. Embassy. In coming weeks this core group would guide nearly all Yambuku-related activities, operating in several languages, crossing often difficult political and cultural boundaries, each professional adhering to his or her designated responsibilities and all answerable to the acerbic, often flat-out outrageous Johnson.

  Niceties and introductions taken care of, Johnson swiftly guided the multilingual group through its marching orders, delegating responsibilities and laying out a strategy for attack that drew heavily from experiences with Machupo and Lassa. Breman was put in charge of epidemiology investigations: doing the detective work necessary to determine who was spreading the disease, how, and with what clinical results. Together with Belgian Jean-François Ruppol, Piot, Zairian scientist André Koth, and Sureau, Breman was told to prepare for immediate departure for Yambuku.

  Johnson reminded the group that the virus they were dealing with was extraordinarily dangerous, and using colorful language peppered with obscenities, ordered everyone to take their temperature twice a day, follow to the letter Isaacson’s recommendations for protection, and always work in teams.

  That night Piot, Sureau, and Breman prepared, each in his own way, for the next day’s journey to Bumba. Young Piot, who had never before set foot outside Europe, was anxious to get out of the wedding suit his government had instructed him to wear, and see the infamous nightlife of Kinshasa. All night long the Belgian doctor strolled the streets of the city, chattering incessantly with the friendly Zairois, listening to the ramba rhythms in nightclubs, and sampling local drinks and delicacies.

  “This is wonderful!” Piot exclaimed to local team members who showed him the town. “What an exciting place.”

  He didn’t want to sleep, or think about the epidemic. Piot arrived at the airport the following morning groggy and caffeine-sobered. Though sleepy, he grew increasingly alert as the time for the team’s departure drew closer.

  Sureau was also excited as he sat in the President’s plane awaiting takeoff.

  He had to admit, however, that he was “a little scared of the unknown,” and had been in no mood to party all night with the young Belgian. Instead, Sureau had paid another visit to Mayinga, finding her condition further deteriorated. The young student nurse was emotionally overwrought. He reviewed virus containment and protection procedures with Isaacson. And from her got a copy of Marburg Virus Disease by Martini and Siegert,12 which he was now trying to read aboard the Hercules jet.

  Breman, feeling the dull disorientation of jet lag, had spent the evening working out logistics with Johnson and Ruppol and making sure the proper equipment found its way into the plane’s cargo bay.

  After a three-hour flight the jet landed on Bumba’s tiny airstrip. The terrified Air Force pilots left the engines running and ordered the scientists to get out as quickly as possible. Piot drove their Land-Rover, packed with supplies, out of the cargo hold, and hadn’t even parked it before the panicky pilots began to taxi for takeoff.

  Piot could feel the eyes of hundreds of people upon them as he inspected the Land-Rover. The airstrip was lined many rows deep with anxious-looking people.

  “My God, the entire town must be here,” he whispered to Sureau.

  “They’ve been under quarantine for days,” Breman reminded his colleagues. “They’re fed up, and they’re scared. I imagine they think we’re going to perform some kind of miracle.”

  That night the scientific team shared the hospitality of Catholic missionaries in Bumba, who brought them up to date on radio messages from Yambuku. Bumba physicians Ngoi Mushola, Zayemba Tshiama, and Makuta briefed the foreigners on their clinical observations, noting that the epidemic had spread to several villages around Yambuku.

  Sureau passed the final hours before retiring that night in quiet discussion with the grief-stricken priests of Bumba. Joel and Peter, however, were too high on adrenaline and curiosity to sip vermouth with aging clerics, so they went to a folk music festival at the local cathedral.

  The following morning the group looked in on a handful of mystery disease patients at the Bumba hospital, and, fortuitously, met Dr. Massamba Matondo, chief physician for the neighboring Lisala province. Massamba, a careful doctor with an instinct for epidemiology, had already toured the epidemic area and he told Sureau the disease was claiming residents of at least forty-four villages in a fifty-mile radius around Yambuku.

  With Massamba and Bumba missionary Father Germain Moke, the scientists made their journey to Yambuku later that morning in two Land-Rovers. The fifty-mile drive took all afternoon. Rarely could the frustrated drivers gain enough speed on the bumpy muddy roads to get out of second gear.

  More than three hours later, they reached Yambuku.

  They turned off the engines and immediately felt the sad silence of the place. Gone were the noise and activity of typical Zairian villages, the long lines of chattering women and children waiting for vaccinations, the vendors selling their wares. Indeed, gone were the people, altogether.

  Piot spotted Sister Genoveva’s odd white gauze “cordons sanitaires” strung about the mission, and a sign in French that said: “Do not enter; to call the Sisters ring the bell.” As he approached the bell three nuns came running out of one of the buildings, calling, “Don’t come near! You’re going to die! You will die! Stay away!”

  Recognizing their Flemish accents, Piot jumped over the “cordons” and shouted greetings in their shared native tongue. Overwhelmed at hearing Flemish, the nuns broke down, sobbing. Sureau, Ruppol, and Breman quickly joined Piot in his efforts to comfort the women, and the Sisters were pleased that Jean-François had, as promised, returned to their devastated outpost. As tensions and emotions eased, the scientists unloaded their equipment and followed the Sisters to the school. Closed since the fourth week of the epidemic, the barren classrooms became their temporary home.

  Over dinner and plenty of wine the Catholic teachers and clerics poured out their stories for hours on end, while the visitors patiently listened, asked gentle questions, and occasionally jotted down notes. Sister Marcella, who had been
keeping logs of the dead, presented her grim lists to Sureau.

  Speaking in a deliberate monotone, which seemed to help her keep her emotions in check, Sister Marcella explained that in the past month 38 of the 300 residents and employees of Yambuku had died, including all the missionary nurses, four out of six Zairian nurses, one of the three padres, and one of two hospital laundry workers. Then she gave the scientists a sobering list of villagers afflicted. The visitors realized they would have to go to every single village, conducting a house-to-house investigation. No other approach would do.

  Sister Marcella also volunteered that the first unusual medical problems at the hospital may have occurred in August, when three women died in close succession on the obstetrics ward. They had bled to death after giving birth. The Sister had checked hospital records for the same time periods in 1975 and found no such cases, and she was unable to tease out of the general hospital records cases of anything similar to the strange new disease prior to August 1976.

  “It is new,” she told them. “It is definitely something new.”

  V

  While the exhausted scientists slept on the hard floors of the Yambuku school, Mayinga lost consciousness in Ngaliema’s Pavilion 5. And the commission members argued late into the Kinshasa night about contingency procedures for handling infected team members.

  Joe McCormick had just started unpacking his hundreds of crates of laboratory supplies for Lassa research when he received a cable from the CDC in Atlanta, instructing him to temporarily abandon the lab outside Kenema, Sierra Leone, and make his way as quickly as possible to Kinshasa. The cable stated that his familiarity with northern Zaire, coupled with his epidemiology skills, made him indispensable. He was instructed to bring with him the portable glove-box lab he and Johnson had rigged up in Atlanta just weeks earlier, and other equipment that was needed at Ngaliema Hospital for testing and screening blood samples and preparing antisera against the mysterious disease.

  Just a few months earlier, having heard of McCormick’s exploits in Brazil, Johnson had snagged Joe one day in the CDC hallway.

  “I’d like to send you to Sierra Leone,” Johnson said, “to figure out just how widespread Lassa really is.”

  McCormick hadn’t been in West Africa, and the Lassa puzzle sounded “damned interesting,” so in March 1976 he packed and prepared to set up a one-man Lassa research station in Sierra Leone. Just before he left, McCormick and Johnson rigged a glove-box contraption similar to the one Karl had used in Bolivia, and Joe gathered enough equipment to study the virus safely under even the most primitive conditions.

  Within a week he had his Lassa research station: a small building 200 miles from the capital, outside the town of Kenema. It contained two chairs and his cases from Atlanta. He’d just uncrated Johnson’s portable laboratory when the cable arrived from Kinshasa.

  McCormick knew there was no easy way to get from Freetown, Sierra Leone, to Kinshasa: virtually all flights between African countries were both notoriously expensive and unreliable; nearly all went from one African country to another via the formerly colonial European countries.

  For three days McCormick bluffed, bullied, and bribed his way onto airplanes and through customs in Freetown, Abidjan, and, finally, Kinshasa. He completed the 2,000-mile journey with all equipment crates, remarkably, intact. At Kinshasa’s N’djili Airport he sprinkled a little Kiswahili and Otetela in with his French, and eventually convinced customs and immigration officials to let his crates into the country, unopened, undamaged, and unexamined.

  Meanwhile, the scientific team awoke with the Yambuku dawn, relayed an abbreviated version of Sister Marcella’s reports by radio to Bumba (from where they were ultimately relayed to Kinshasa), breakfasted, and set out in different directions in four teams to inspect the villages. Piot and Sureau were teamed up, and Sister Marcella, ecstatic to be outside the mission after so many days of quarantine, acted as their guide.

  “We must limit the numbers of us who are exposed to this virus until we determine how infectious it is,” Sureau told the group, instructing that only he and Piot should draw blood.

  The trio first arrived in Yalikonde, close by Yambuku, where they quickly learned how to gain the trust of the fearful villagers. A working pattern developed that was repeated in ten villages that day. It would begin with an amble about the middle of the village, during which time the leading elder of the community would introduce himself. The group would discuss the weather for a while, until the elder invited them to share some arak.

  “This stuff is pure methanol,” Piot whispered.

  “Drink!” Sureau commanded.

  After the arak burn had made its way down their throats and into their stomachs, the Yalikonde elder introduced the white men to Lisangi Mobago, a twenty-five-year-old man who had been struggling with the disease for six days. The visitors examined Lisangi, who was far too weak to protest, and drew a blood sample.

  Everywhere the group went they noticed the people had taken remarkably wise measures to stop the epidemic’s spread. Roadblocks were staffed around the clock near village entries, virtually all traffic on the Ebola and Zaire rivers had come to a halt, the ailing villagers and their families were kept under quarantine, bodies were buried some distance away from the houses, and there was little movement of people between communities.

  “These people have really got their act together,” Piot told Sureau, who was also impressed by the steps taken.

  In one village about ten miles from Yambuku, Piot and Sureau found a husband and wife lying side by side in their hut, both in the final throes of the disease. Pierre took blood from the husband while Peter prepared the wife’s arm.

  Sureau shifted his weight to face the wife, found a vein, and inserted his syringe. As he released the tourniquet and watched blood slowly fill the tube, the husband let out a deep groan and died. The wife cried out, Sureau quickly withdrew his needle, and she rolled over to embrace her dead husband.

  Shaken, they stepped out into the sweltering sun and whispered anxiously. If the husband had died while Sureau was taking his blood, the villagers might have attacked the men, accusing them of responsibility or, worse, of homicide. As it was, many villagers were taken aback when the tall white men—especially Breman and Piot, who both stood over six feet—donned goggles, rubber gloves, and surgical masks before entering the homes of the infected.

  For their part, the Europeans and the American had no idea whether these modest precautions were adequate to protect them from what they now understood firsthand was a particularly horrible disease. Breman was a bit anxious that villagers might be offended by his protective gear, but he was also, as the blunt American put it, “scared shitless.”

  “I’m no Marlboro Man, and I don’t mind admitting I’m really frightened. As, I think, we all should be,” Breman told his colleagues, who vigorously nodded their concurrence with his sentiments.

  When the team members reunited at the mission after their first long and emotionally exhausting day in the villages, they compared notes and agreed that the epidemic had taken a terrible toll—in some cases claiming entire families—but the worst of it seemed to have passed. Breman, in particular, was relieved to see that initial accounts saying entire villages had been exterminated by the virus were gross exaggerations. Without knowing its cause or cure, the people had wisely taken many proper measures to slow the virus’s spread. The scientists humbly agreed that their scientific expertise had not been necessary to arrest the epidemic.

  But it would require the best their collective talents could muster to solve the mysteries of where the strange virus came from, how it was spread, and how best to prevent its resurgence.

  That evening as they relaxed with more mission wine, layered atop several rounds of village arak, a day-old radio communication reached them from Kinshasa,
via Bumba.

  “Mayinga died late the night of October 20,” it stated flatly.

  Sureau was devastated, as were the Sisters, who felt profound gratitude for the student nurse’s courage in tending to Sisters Edmonda and Myriam.

  “What we are dealing with is a virus like Marburg, but more pathogenic. A super-Marburg. I don’t feel alarmed, but I do feel a sense of disagreeable uncertainty. Who will be the next victim among the caregivers? Sister Donatienne? … Margaretha or me? The incubation time is usually eight days! How many more victims will there be in the villages? What can be done to stop this epidemic?” Sureau asked.

  The others looked at Sureau in sad agreement, for he was voicing thoughts shared by all.

  Though Sureau had clung to the increasingly dubious hypothesis that the epidemic was caused by some sort of Marburg virus—probably in a spirit of hopefulness on Mayinga’s behalf—Breman had no such illusions. Breman had been on the phone with Pat Webb at least twice a day for the three weeks prior to his arrival in Kinshasa. He knew precisely what Webb had discovered, and he carried with him eight-by-ten microscope photos of the enemy. As he wandered about the villages, Joel would hold up the “???? virus” pictures of fuzzy, curled, wormlike microbes and explain to the Zairois that this new entity was the cause of their suffering.

  The trained epidemiologist of the group, Breman laid out a symptomatic definition of the Yambuku disease that the four teams should use as they scoured villages for cases.

  That night, Sureau radioed Bumba to tell Kinshasa that first surveys showed 46 villages were affected, with over 350 deaths.

  For the next few days the scientists worked in Yambuku, Bumba, and the villages in between, having no way to communicate either with Karl Johnson in Kinshasa or with one another once they split off daily to investigate separate villages. Sureau and Breman occasionally received garbled messages about helicopters due to arrive with more experts and better equipment. When the copters failed to arrive, they simply assumed the messages were mixed up.