The Coming Plague

by Laurie Garrett

  And he gave Baron a quick sketch of the political and social situation. Tensions between the Muslim Nubian and Arab north and animist and Christian south remained high, though no civil war had flared since 1972, when Colonel Jaafar Nimeiri granted the southern area some degree of autonomous power. The Nimeiri government in Khartoum continued to maintain highly centralized government oversight over all matters deemed of national interest, including disease control.

  Since McCormick’s last visit to the region during the 1976 Ebola outbreak, the relationship between Sudan’s north and south had grown more strained, and the Nimeiri government had been chipping away at the scope of autonomous rule in Juba. Though few realized it in 1979, the country was on the brink of a civil war that would flare up when Nimeiri rescinded southern self-rule in 1983 and would persist for over a decade. In 1979 the most visible signs of a rift between Khartoum and Juba could be seen in government-financed facilities in the south: schoolrooms without desks, books, or teachers; unpaved, often impassable roads; almost nonexistent postal services; no central electricity outside Juba; and hospitals lacking any furniture save the steel-framed, unmattressed beds.

  Twenty-four hours after he got the call from WHO, McCormick, with Baron in tow, was in Khartoum getting a quick briefing from federal health authorities. Anxious to get to N’zara as soon as possible, McCormick left Baron behind in Khartoum to arrange methods of air-shipping tissue and blood samples to Atlanta, set up some sort of communications system, and smooth over relations in the capital.

  The next morning, McCormick had breakfast in Juba and began what would be a maddening three-day search for transport to N’zara. The area, which had been under strict quarantine for several days, was almost completely lacking in gasoline for the handful of functioning Land-Rovers and ancient British vehicles that comprised the local government fleet. Furthermore, the people of Juba were terrified: nobody was willing to guide McCormick into the epidemic zone.

  Using every means of persuasion at his disposal, including offers of cash, McCormick finally garnered a police airplane and a pilot who agreed to fly him into N‘zara on September 22. En route, the pilot told McCormick that he would land but not stay. For the entire flight, Joe tried cajoling, threatening, bribing, and instilling guilt in the frightened police pilot, hoping to persuade him to remain in N’zara long enough for the scientist to gather samples that the pilot could fly up to Baron in Khartoum.

  Ultimately, promises of great financial reward upon arrival in Khartoum triumphed over the pilot’s anxieties, and a deal was struck: the pilot would remain inside his plane, having no contact with anybody in N’zara, until dawn.

  The plane touched down at 5:30 p.m. on the grassy field outside N’zara, McCormick hurriedly reminded the trembling pilot of the rewards awaiting him in Khartoum, swiftly gathered his supplies, and set out to find his designated translator.

  “I’ve only got a few hours, and it’s going to be dark soon,” McCormick told the young schoolteacher who translated his English into the local dialect. “I need to see the sick people immediately.”

  The translator nodded and led McCormick through the hamlet of mudand-wattle structures to a round hut on the periphery. Lighting his kerosene lamp and shouldering his medical bag, McCormick stepped inside.

  When his eyes adjusted to the darkness only dimly lit by his upheld lamp, McCormick saw what he would later describe as a vision from hell. Some twenty men and women lay upon grass mats, crammed one against another in a small, dark atmosphere of overpowering heat and stench. Most were in agonizing pain, horribly ill, groaning aloud or crying out in demented visions. Some, their skin in excruciating pain, had torn off their clothing and lay in naked terror.

  McCormick took a deep breath, stepped over to the first ailing man, and resolved to draw blood samples and gather vital statistics on every person in the room before dawn.

  All night long McCormick, wearing only latex gloves and a constantly steamed-up respirator for protection, knelt beside the Ebola victims, giving them thorough physical examinations, painstakingly noting all information on a pad, and taking blood samples.

  Shortly after midnight, McCormick reached the midway point in his work: an elderly woman who was delirious, burning with fever. She seemed to be hallucinating, and McCormick assumed that his masked visage was disturbing. He carefully set the lantern on the dirt floor next to his bent knees, placed a tourniquet on the woman’s upper arm, and uncapped the needle on a fresh syringe. McCormick paused, waiting for calm to come over the woman, then deftly inserted the needle in the ailing woman’s arm, simultaneously releasing her tourniquet.

  The instant the needle hit her vein, the woman thrashed wildly, the syringe popped out and landed in McCormick’s thumb. Horrified, he swiftly recapped the needle, squeezed his thumb, and applied disinfectant to the invisible microscopic wound site. He looked at the frenzied woman, so ill she probably hadn’t even realized what transpired. And then he held his watch up to the lantern.

  “Only five hours until dawn’s first light,” he thought. Mustering composure and deliberately shoving aside all thoughts of being stuck by the needle, McCormick scrupulously completed his rounds, prepared all the samples for shipment, putting them inside a small tank of liquid nitrogen and placing that in a case of dry ice. He then raced out to find the pilot.

  Once the plane was aloft, McCormick let himself feel his exhaustion—and fear. He asked his translator for a place to sleep, and followed zombielike, carrying his supplies to a thatched-roof hut. He reached into his bag and withdrew a supply of precious Ebola antiserum that Joel Breman and Peter Piot had collected in Yambuku three years earlier.

  “Nobody really knows if this stuff works,” McCormick mumbled as he injected himself with two units of plasma. He then grabbed the radio he’d brought from Atlanta, called Juba, and got the signal relayed to Khartoum. Once Baron was on the line, he told the young doctor that samples were on their way and the pilot should be rewarded.

  “Oh, and by the way, I seem to have stuck myself. I just mainlined some plasma, and I think I’m going to pass out for a while,” he told Baron.

  He then downed the only medicine in which he had any genuine confidence, given the situation: a bottle of Scotch.

  Twelve hours later, he awoke to a N’zara late afternoon, stepped out into the 100-degree heat, and took stock of the situation. It was clear that Ebola had struck again. It was also obvious that he had been exposed to the virus. Recalling his previous experience with Ebola, McCormick figured the virus would incubate for five to seven days before he got sick, leaving him plenty of time to get to the bottom of this epidemic.

  “I was not in a panic,” McCormick would explain years later. “If I got a fever, my plan was I’d get on the horn, get a plane in there, and evacuate to Europe. I’d faced the possibility of dying before, and I just didn’t see the point of going to some hospital and getting everybody in a stew, sitting and waiting to get sick, and thinking all the while about the work I should have been doing in N’zara.”

  With a shrug, he added, “I’m a fairly stoic Midwesterner.”

  Nevertheless, McCormick had no death wish. Waiting for him in Atlanta were his wife and three children, aged two to nine years.

  Over the next week, McCormick, joined by Baron and Zubeir, reconstructed the history of the N’zara epidemic, collected more samples, and took steps to stop the outbreak. All the while, he kept a constant eye on that “death hut,” as he called it, keeping track as the dead were removed by relatives for burial.

  Meanwhile, he was determined to observe enough patients in Yambuku in sufficient detail to formulate a copious description of the signs and symptoms of the disease. The disease seemed to strike people very suddenly: one moment an individual might be laughing and sharing local moonshine with a frien
d, the next he would have a searing headache, be drenched in sweat, and feel too weak to stand. It was this seemingly instantaneous illness that the Sudanese people found especially terrifying. Over the next three days, things would escalate rapidly. Patients would tremble with chills, fevers would soar over 105°F, and every joint and muscle would ache with pain so severe that the Ebola victim could find no position in which to comfortably lie down or sit. Their throats would become so sore that most couldn’t tolerate swallowing their own saliva. Eating was out of the question.

  By the fourth day, hemorrhaging would begin. Ebola victims would vomit blood, excrete blood, bleed profusely from their gums, and stare at McCormick through bloodshot eyes.

  McCormick soon realized that the frequently used expression “the patients bleed to death” wasn’t accurate in the case of Ebola—or for Lassa for that matter. It wasn’t the bleeding that killed the Sudanese Ebola victims, he concluded, but shock due to fluid loss. Somehow the virus was causing the endothelial linings of the patients’ veins to break down, giving rise to leakage of water from the bloodstream into neighboring tissue. As vascular volume decreased, the patients went into shock. If fluids were pumped into the patients’ bloodstreams, the result was death by pulmonary edema, because leaking veins in the lungs flooded the airways with fluids.

  McCormick treated patients with the Yambuku plasma, with mixed results: some improved, whereas others showed no response to the putative antiserum. He wasn’t convinced it was useful, which added to whatever concern he allowed himself to feel about his own status.

  One afternoon, he spotted the old woman from the death hut strolling through N’zara, a jug of water on her head, clearly full of energy. McCormick was ecstatic. CDC blood test results cabled from Atlanta shortly thereafter indicated that she alone among those in the death hut was uninfected. Whatever her ailment, it wasn’t Ebola.

  And Joe McCormick had never been infected with the deadly virus.

  With the passing of days the people of N‘zara concluded that the odd-looking white man with the weird face mask did seem to have special powers. They observed his actions and followed those orders that seemed to make sense. The key order they wouldn’t follow, however, was “bring your sick and dead to N’zara Hospital.” And for good reasons.

  It seemed the hospital was, as it had been three years earlier during the first Ebola outbreak, the focus of the epidemic. Shortly before McCormick, Baron, and Zubeir arrived, two nurses in the hospital died of Ebola, apparently contracted from patients. The people knew that many checked into N’zara Hospital; few checked out.

  The second and far more difficult problem was the fate of the dead. In 1976, Don Francis had allayed the people’s spiritual concerns by performing the ritual burial practices himself, but the epidemic in 1979 was too big for McCormick to handle the evacuation of wastes from all the bodies—especially since those wastes undoubtedly contained viral contaminants.

  So he settled on a novel idea: let those attending funerals wear respirators, gloves, and surgical garb, and conduct the burial preparations themselves. In exchange for such protection, the relatives usually allowed McCormick to remove tissue and blood samples from the bodies.

  Day after day Zubeir and McCormick scoured the high Sudan grass in search of hidden communities, and negotiated for the sick and dead. It was a process fraught with cultural difficulties for both sides, but they usually succeeded.

  Within a month, the team had the disease under control and was able to recommend that Khartoum lift the area’s quarantine: not a moment too soon, as the entire province was out of gasoline, most food supplies, and even medical supplies. Famine would have quickly followed.

  When the team reconstructed the events of the summer of 1979, they discovered many parallels with the 1976 outbreak, but were still unable to say where the virus came from. Once again, the first case involved a man who worked in the run-down colonial-era cotton factory that was filled with huge swarms of bats and a vast array of insects. He fell ill on August 2 and died of the disease in N’zara Hospital three days later.

  Three of the man’s family members who cared for him fell ill. So did a man who lay in the bed alongside him in N’zara Hospital. A woman who frequented the hospital ward, tending to her ailing husband a few beds down from the first man, got Ebola. And the two nurses on the ward got the virus.

  Every additional illness involved members of the families of those first five cases or close friends who tended to their illnesses or burial preparations. All infections could be tied to some direct blood or fluid contact between an ailing Ebola victim and another individual. The best nurses—those who provided the closest care for the patients—were five times more likely to be infected than their more aloof colleagues.

  The team was able to find fifty-six Ebola cases, many hidden in the tall grasses. Sixty-five percent of those who got infected died.

  Though it seemed obvious to McCormick that some Ebola-carrying animal or insect lurked inside the cotton factory, none of the fauna samples he sent to the CDC were Ebola-positive. Their inability to pinpoint the reservoir for Ebola would bother McCormick for years, nagging constantly at the back of his mind whenever he had reason to recall the events in N’zara. He would always tell anyone who asked, “It’s probably the bats. We just have to get in there and capture a few more of them and we’ll find the virus.”

  Barring identifying the reservoir for Ebola and eliminating the culprits from the human ecology of the N’zara area, McCormick suspected isolated cases of the disease would always crop up.

  “Because the cultural and social structure in Sudan tends to limit contact with severely ill persons to a few adults in a relatively secluded compound, sporadic cases of Ebola virus disease may have little impact on the community at large,” the team wrote, summarizing their findings.47 “In this outbreak, however, the hospital appeared to be the focal point for dissemination of infection to several family units after the admission of the index patient.”

  As was the case with Lassa, poorly run hospitals operating under conditions of extreme deprivation were the amplifiers of microbial invasions. What might have otherwise been individual illness, limited to one or two cases of Ebola, was magnified in a hospital setting in which unsterile equipment and needles were used repeatedly on numerous patients. N’zara Hospital couldn’t afford mattresses for its steel bedframes or penicillin—it could hardly be expected to throw away every single plastic syringe simply because it had previously been used.

  McCormick was at a loss for a solution. Once again, elimination of a disease threat seemed inextricably bound to economics and development. The poverty of southern Sudan exceeded anything he had seen before, and McCormick had little reason to hope that some government or agency with the wherewithal to do so would deem it politically expedient to assist such godforsaken parts of the planet.48 Yet McCormick felt certain that Ebola and other dangerous diseases would continue to haunt the most impoverished communities on earth, constantly threatening to explode into epidemics, some of which might one day lap at the shores of the planet’s richest nations.

  Out of such poverty, from the African Serengeti to the burned-out tenements of the Bronx, would soon come microbial invasions that would bear out McCormick’s prophesy.

  8

  Revolution

  GENETIC ENGINEERING AND THE DISCOVERY OF ONCOGENES

  Man is embedded in nature. The biologic science of recent years has been making this a more urgent fact of life. The new, hard problem will be to cope with the dawning, intensifying realization of just how interlocked we are. The old, clung-to notions most of us have held about our special lordship are being deeply undermined.

  —Lewis Thomas, 1975

  Scientists at the Massachusetts Institute of Technology have completed the synthesis of the first
man-made gene that is fully functional in a living cell.

  —Massachusetts Institute of Technology press release, August 30, 1976

  The revolution happened with such astonishing speed that few participants fully appreciated what had transpired. The collective consciousness of science and medicine changed in the blink of a historic eye, rendering those who failed to adapt obsolete overnight. In less than five years every aspect of biology and medicine was so thoroughly shaken to its core that science students trained afterward thought it had always been so. The excitement could be felt from the floors of the world’s stock exchanges to the halls of parliaments worldwide.

  Just as the hopeful spirits of the post-World War II scientific conquest of the microbes seemed to be flagging, humanity discovered genetic engineering.

  When science learned how to manipulate the genetic material of plants, animals, and microbes—the DNA and RNA—an entirely new world revealed itself. Suddenly it seemed possible to understand the secrets of the microbes, appreciate at the molecular level how the human immune system destroyed (or failed to destroy) its microscopic challengers, and invent radically new weapons to use in waging war on disease.

  Once again, optimism pervaded biological research. Once again, scientists predicted bold victories over everything from cancer to malaria. The speed of discovery from the early 1970s into the 1980s was dizzying, even for those who started it.

  “I wasn’t surprised about much of anything until 1966,” declared Sir Francis Crick in a 1983 interview. “But after that, well, the last ten years have surprised us enormously. We had no idea. No idea.”

  The English scientist turned and nodded to his American colleague, James Watson, who readily agreed with Crick’s assessment. Together in 1953 at Oxford University, with the unwitting “assistance” of X-ray crystallographer Rosalind Franklin, they discovered the relationship between an enormous and strange molecule, deoxyribonucleic acid, and human genetics. They proved that DNA contained the genetic code of life, a discovery for which the men shared the Nobel Prize in Medicine. 1