by Piot, Peter
As our camaraderie deepened, I began to develop great admiration for the power of American science, management, and entrepreneurship. I essentially shed the primitive anti-Americanism that I had developed, in common with so many Europeans at the time, and told myself that we Europeans should stop complaining about the United States, learn the best from them, and get our act together. I also decided I wanted to go to the United States for further firsthand experience of American science. I was determined to spend the rest of my life working on health in Africa; I felt that I would be marked for life by what I had seen of the degrading conditions of extreme poverty, and the intolerable suffering and disease to which it exposes people. But to do this as well as possible, I needed more training, more knowledge, and more skill.
In early December, Del Conn—a Peace Corps volunteer who had joined us from Kinshasa to provide precious logistic support—came down with fever and rash. Del was less lucky than I had been when I had my two days of bad diarrhea in Kinshasa: he was put in a plastic isolator and flown to Johannesburg with Margaretha Isaacson. Fortunately he did not have hemorrhagic fever—I don’t know what he actually had—but he must have felt extremely lonely and scared in his plastic tent, with Margaretha as his caregiver.
Sometime after Del’s departure, Stefaan Pattyn visited us, out of the blue. I now felt empowered enough to have a normal relationship with him.
On December 22, we finally flew out of the epidemic zone, to be replaced by David Heymann, a young American from the CDC who would be doing post-outbreak surveillance for two months. I had to hand it to him: it was nearly Christmas, but David was not only prepared to miss out on the usual holiday celebrations, he was also prepared to ensure the less than glorious work of postepidemic surveillance. This means ensuring that there is no recurrence of the epidemic and continuing the basic epidemiological surveys, while comforting the nuns and providing assistance to the hospital. He had lost his eyeglasses en route, and there was no optician for a thousand miles in any direction; I wholeheartedly wished him good luck. (As with so many members of the original Ebola team, our friendship developed further in subsequent years, as our paths crossed time and again—most recently when he became assistant director-general of WHO in Geneva and, again, in London, where we currently work together at the London School of Hygiene & Tropical Medicine.)
When the plane arrived to pick us up there was another big fight with the pilots of the Buffalo plane because General Bumba had demanded they bring a stock of rattan furniture back to Kinshasa, and a number of other people had bribed them to be allowed on board, so there was no place for our samples or lab equipment. (The quarantine had been lifted but no boats had yet arrived in town.) I argued and swore and joked around and cajoled.
Nonetheless, they ultimately conceded our right to board the plane, and allowed us to load our Land Rover, boxes, and nitrogen-gas canisters on board. Yet another storm was beginning. As we took off, the plane—overloaded and badly loaded at that—lurched and hit the trees. I could feel it straining against the wind to pull up and take flight. We had no seat belts, so we were flung about, and several of us were hit by heavy flying crates. There was quite a bit of blood and some shouting, and I thought, This time, this is it.
But weirdly I wasn’t thinking about myself anymore. I looked over at the crate that held the liquid-nitrogen canister with all those precious samples of sera for further analysis and thought, Shit, all this work for nothing.
But then we pulled up, and out, back to Kinshasa.
I WAS HOME just in time for Christmas, after more than two months of absence, instead of the 10 days as originally planned—a quite transformed person. It took me a while to get used to the family and work routine again, to the absurd range of choices in supermarkets, and to the fact that, after all, Belgium is a well-functioning society. (Whenever I heard people say that we didn’t need government, I reminded them what it is to live and do business in a country without a functional government and without the rule of law.)
I was grateful to be alive, and had learned that anything can happen, good and bad, in life. But also that more is in me than I assumed. Ebola showed dramatically that, in contrast to prevailing medical opinion in the 1960s and ’70s, the world would experience a seemingly never-ending series of new infectious disease epidemics in humans and animals. This first-known outbreak of Ebola hemorrhagic fever was probably also the first example of highly integrated international collaboration to tackle an outbreak—a collaboration that was informal and ad hoc, driven by a very diverse group of scientists with a passion for solving problems in the field, and committed to working as a group (for example, we decided early on to publish our findings as an international commission, rather than as individuals, thereby avoiding the so-common conflicts among researchers about authorship). It was one of the last major disease outbreaks without global media attention, as neither CNN nor Internet-based social media existed in 1976. As so eloquently reported by Laurie Garrett, when Ebola hit Kikwit in 1995, 19 years after the false alert we investigated, there were nearly as many journalists as epidemiologists and doctors on site, which was a mixed blessing for those working in Kikwit, but certainly raised the world’s understanding that we are under constant threat of new pathogens. Since then, there have been about 20 outbreaks of Ebola infection, nearly all concentrated around hospitals in Africa, and with very high mortality. In general it is an infection that causes epidemics only if basic hospital hygiene is not respected, and is really a disease of poverty and neglect of health systems. The heroic and well-meaning sisters in Yambuku had dramatically shown that doing good is not enough, and can actually be dangerous if it is not bedded in technical competence and sound evidence. Health, economic, and social development are unmistakably intertwined.
Finally, 35 years later, it seems more and more likely that my boss at the time was right: fruit bats are probably the reservoir where Ebola virus hides in between epidemics in humans and apes. If only I had listened to good old Pattyn, who died in 2008.
• PART TWO •
CHAPTER 7
From Ebola to Sex and the Transmission of Infection
WHEN WE RETURNED to Europe, Guido and I paid a visit to the convent of the congregation of the Sacred Heart of Our Lady to give the sisters a full report. S’Gravenwezel is a small town north of Antwerp, and the huge convent was an extraordinary place, very formal and grim; it felt like another era. We arrived at the appointed time one dark, almost-snowing afternoon in January. We rang a large bell and the heavy convent door slowly opened. A sister walked us through a series of freezing cold corridors to a waiting room. Finally we were called on to speak before the mother superior and all the assembled nuns.
I almost expected candlelight. I once again marveled at the series of historical events that had projected these women into a tiny village in Central Africa. You could hear a pin drop when we reminded them how the four sisters had died, and they asked too many questions to which we had no answer. We discussed also how we could raise money to refurbish the hospital, and they were very keen to recruit a doctor for Yambuku. Even after our presentation I’m not sure that the implications, in terms of their responsibility for the epidemic, had really sunk in. They profusely thanked us and said that they would pray for us, and then we focused on raising money for Yambuku.
This made me feel we hadn’t done our job, frankly. Guido insisted that we shouldn’t underscore their guilt: he saw their heroism and goodwill, their dedication, and loved them for it. But I thought it could have been an important lesson. Goodwill is not enough. You need to be competent, you need to know what you’re doing, or you may do more harm than good. To be fair, it was true that they had had very little funding, extremely poor training, and they had not been able to pay for any doctors in the Yambuku hospital. Thus we promised to help them ask for government money so they could pay for a doctor at the mission. But I couldn’t help wondering how many more mission hospitals in Africa were as underequipped and poorly run as
Yambuku, and what earthly difference one doctor could make.
I was feeling sobered about the whole experience of traveling to Zaire. Maybe it was a kind of postcombat depression. I saw how irresponsible we had been throughout the whole assignment. No insurance, as traveling to an epidemic zone was an “extraordinary risk,” against which the institute had not insured employees. No evacuation plan: the Americans had one, and all we did was rely on their probable help. Post hoc, I felt scared and angry at the scale of the risk.
I was also furious, because Pattyn without intending to do so, tried to deprive me of my reward. I was one of fewer than ten doctors who saw a case of Ebola; I participated in isolating the virus. One afternoon I walked into his office and saw on his desk the manuscript of the article he was writing to report the discovery of the virus. Neither my name nor Guido’s was on it.
In a sense, this was how things often had worked in science in Europe until the 1970s: the young people did the work, and their bosses took the credit. Pattyn wasn’t doing anything unusual, but it really made me mad. I grabbed the paper, went to find Pattyn, and calmly told him, “I am going to be an author of this article and Guido is going to be an author of this article!” Pattyn simply dissolved. He blinked a little bit and mumbled something about it being just a draft, after all, and wrote our names in right there while I was watching.
It felt like a small victory, however. Work at the lab seemed routine. My life—despite the comfort and friendliness and safety of it—paled in comparison with the drama of Ebola. A number of us must have felt the same way, for when the World Health Organization (WHO) convened a meeting of the international commission that month of January 1977 at the London School of Hygiene & Tropical Medicine, there was a tense and scornful dispute between the Zaire team and the group from Sudan—one that seemed way too emotional for its supposed subject. This was my first formal international meeting, and despite all the rituals of each speaker taking the floor and formally thanking everyone, there was tension. Each team accused the other of poor statistics. Ebola had killed only about 50 percent of its victims in Sudan, whereas the figure in Zaire was far higher, more than 80 percent. Later on it turned out that the two strains of the virus were different: almost unbelievably, there had been two simultaneous but unrelated outbreaks of the same, previously unknown disease within a radius of 500 miles. Again, there was a lesson here: something that may appear to be completely unlikely—even ludicrous—can happen.
The London School was an imposing establishment near the British Museum, its building nearly a whole city block, lined with the names of famous physicians of tropical medicine, which seemed to radiate all the imperial power of the British empire. Little did I dream that I would much later be appointed to direct this august institution. Too intimidated to speak much, I listened as my colleagues agreed on a number of recommendations for WHO. The main proposal was that mechanisms should be developed to identify and react promptly to new outbreaks of hemorrhagic fever, with mandatory reports to WHO of all new suspected cases, a Disaster or Outbreak Fund, and a constantly updated list of experienced people ready to participate in a rapid deployment team. We also recommended training for people who would coordinate expeditions; specific operational plans for surveillance, epidemiological studies, lab support, logistics, communications and information to the public; lists of the kinds of specimens needed for differential diagnosis, and where to send them; and a special, detailed checklist of recommended supplies. Basically none of it was ever implemented.
A few weeks later in February Pattyn received a phone call. The Ebola epidemic had perhaps flared up again in Yambuku and this time it might have already spread—maybe even to Belgium. Days before, a patient at the Yambuku hospital—a farmer, with a small shop—had developed what the sisters identified as Ebola symptoms and died. The nuns panicked. Rather than endure more weeks of quarantine and a continuing drumroll of deaths, they bolted to Kinshasa and caught the first available flight to Belgium. They were currently at the convent, consumed with fear.
Pattyn and I went to s’Gravenwezel. The sisters began crying. They could see that in taking flight they had not only abandoned what they conceived as their duty, but they had also potentially endangered other people. (They seemed to have posttraumatic stress syndrome—not surprising given what they went through.)
Then he turned to me. Pattyn wanted me to go back to Yambuku. He said that “we” would do the job without the Americans this time. “We” would get in there and find Ebola’s natural reservoir.
I flew into the zone with Jean-François Ruppol and Dr. Weyalo, a young Zairean internist from the Clinique Kinoise, a brave and good companion. We landed in Gbadolite, the home village of President Mobutu’s mother. Here Mobutu was engaged in erecting a series of three palaces—actually an entire Versailles—in which he and his wife (whose name, amazingly, was Marie-Antoinette) could indulge in his favorite tipple, vintage pink champagne.
Seen from above, the fake lakes and curving balustrades of this Italian-marble confection were simply obscene, a megalomaniac Disneyland that was emblematic of Mobutu’s theft of resources and his distance from his citizens’ concerns. The airport—equipped for intercontinental jets—was huge and empty. Leading from it, a four-lane highway lined with European tulips led past a number of villas said to be under construction for various dignitaries of Mobutu’s régime, all of them jostling for proximity to the Président-Fondateur. Colonialism surely wasn’t much worse than this loathsome régime.
We drove to Yambuku. The whole region was in panic. The mission hospital was deserted, though Sukato, the nurse who had survived Ebola infection, was still there. We stayed for two weeks, from February 7 to 20, trying to develop a clear picture of events. Everywhere we went it seemed much more like an outbreak of rumors than an outbreak of disease. Although the sisters were now using sterile needles for injections, we followed up every possible needle contact we could; none seemed to have an infection. At every village we went to, people said, “Here there have been no deaths”—they were absolutely certain of that—“but in such-and-such a village the fever is back.” But when we went there to check it out, we found nothing.
It was in a way more difficult to investigate a nonevent than an event. You had to prove that something hadn’t happened. We wondered if people were hiding the disease so as to avoid the crippling economic effects of a quarantine, but we reasoned that this would have been a lot to hide. And there were other clues too. I saw no women with shaved heads, and I knew that meant there had been no deaths. People would not give up customs that ran so deep just to fool a couple of doctors. In the meantime we held consultations, and even did some emergency surgery, since the hospital still had no doctor.
In the end it was up to Dr. Weyalo and me to decide whether to quarantine the whole region. And we concluded that there was no need to do it. A single man had died following rectal bleeding. Probably he had had colon cancer. But in a region still seething with fear and tension months after a murderous epidemic that was all it took to ignite a new, quite pointless wave of terror.
I RETURNED TO Antwerp, a tolerant city in these days, and my son Bram was born in April, a few weeks after my return. To my surprise I found that this completely predictable event suddenly shifted my whole view of the world. Before, I felt completely independent. Now someone was relying on me, and a certain insouciant self-indulgence had to give way; I felt responsible, even anxious, about my—our—future. During the long evenings in Yambuku, Joel Breman and I had talked about my plans. I wanted to do more training in the United States. In Yambuku I grasped just how far ahead American medical science truly was. I was particularly impressed by the synergy between several disciplines to tackle a problem, and by the highly critical review of every step in the research process. And there was a joke in Belgium that if you wanted to get anywhere in academia, you needed the BTA diploma—Been To America.
Joel said that he would get me a place at the CDC’s famous field epidemiology
program, the Epidemic Intelligence Service course, which in those days took very few foreigners. But I knew he couldn’t bankroll that; I would have to find the money. Pattyn, meanwhile, urged me to finish my specialty training in clinical microbiology. So while I was applying for various fellowships and sponsorships I continued working at the institute.
But then that spring a new adventure presented itself. André Meheus, a professor of epidemiology at the University of Antwerp, contacted me: he needed someone who knew about lab techniques to accompany him to Swaziland on a mission for WHO. I knew Meheus from my days as a medical student in Ghent; I was then an intern in the Department of Social Medicine where he worked. He was an easygoing and likable man with a lot of contacts, and somehow he had persuaded WHO to fund a five-week mission to southern Africa so that he could eliminate sexually transmitted disease from Swaziland.
When I heard this absurd premise I choked. But André told me this kind of thing was almost routine. WHO made up terms that were deliriously unrealistic and to receive funding you had to promise to fulfill them. But nobody ever checked whether you had achieved the impossible results you’d promised, and so long as you did some work and pushed the buck a little further down the road, everyone was happy. (Incidentally, at today’s WHO this particular attitude has greatly changed.)
It was cold in Swaziland in June—the Southern Hemisphere’s winter. The country was very different from Zaire. There wasn’t the same exuberance of nature—in all its greenness and wilderness—or the same vivid personal style in terms of the way people dressed and moved and spoke. Zaireans were desperately poor, but they looked colorful, elegant, with elaborate hairdos and joyful gestures when they spoke. In Swaziland people were also very poor and were dressed in dingy sweaters.