During my training in Atlanta, they drummed into us, over and over again, the finer points of dealing with the locals. In general, we try to tread very softly. It’s not something I’m particularly good at. In my evaluations over the previous year, “professional relations” was an area that consistently contained the phrase needs improvement.
Hammil looked at me. “Dr. McCormick, we appreciate your offer of support.”
I nodded. I nod when I’m not exactly sure what to say.
Madison sighed. “Well, it looks like we have the lab situation worked out, for the time being, anyway. We’ll use state.” She turned to Verlach. “Baltimore City will head the outbreak investigation?”
“Yes,” Verlach said. “I already spoke to the commissioner. We’ll call state for more hands if we need to. Since Dr. McCormick is already here and familiar with the city, I’m going to ask that he stay on for the investigation.”
Silence.
“I’d be happy to help,” I said finally.
“I thought we agreed to rely on state,” Dr. Madison said.
“For the labs, Jean, not for the investigation itself. Dr. McCormick is more familiar with this situation than—”
“Having CDC involved is going to signal the press—”
“He’s already here, so we can downplay the request. Besides, not having him on board would seem like an oversight.”
“I want to emphasize,” I said, “CDC is here to help at your request. Just as it was with setting up the surveillance program, we can be as much or as little a presence as you want. The investigation and outbreak control will all be locally led, as well as contacts with the press. We’d also be happy to provide you with clinical expertise.”
There was a long silence, and I knew I had just stepped into it somehow. Jean Madison—the Consistently Aggrieved—finally blew. “Oh, come off it. Clinical expertise?”
I stammered, “I’m merely offering assistance if you should need—”
“—if we should need clinical expertise. I know. Thank God you’re there for us.”
I looked at my shoes, covered in light blue paper booties. I sighed.
Jean Madison let out a sharp little laugh. “What do you think we do here, Dr. McCormick?”
“I—”
“We have some of the finest staff in the city to—”
“Jean—” Dr. Hammil said.
“—care for these women.”
“I’m not commenting on the in-house expertise,” I began.
“Of course you are! You seem to think you’re in some backwoods clinic. Surprise, surprise, we have seen our share of sick people, and they do get better.”
“I wanted you to know there are resources available to—”
“Thanks for your input, Doctor. We’ll take it under advisement.” With that, she turned to the door. Before opening it, however, she turned back. “I’m calling a staff meeting, gentlemen, in ten minutes. Dr. McCormick, since you seem to have expertise we don’t possess in-house, I’d like you to present your differential for these women.”
“But I haven’t even seen the—”
She was already out the door.
Another door opened as a nurse, dressed in her moon suit, exited one of the patient’s rooms. She said hello to us, then disappeared into another room. A hospital, even an isolation ward, is a place of constant activity, constant interruption, constant opening and closing of doors. Privacy for patients as well as for their caretakers is an alien concept.
After the nurse was gone, Hammil said, “How old are you, Dr. McCormick?”
“What? I’m thirty-three.”
He nodded. “I guess that explains a lot. Grow up.” He caught Verlach’s eye, turned, and followed Jean Madison into the vestibule. The door closed with a hiss.
CHAPTER 3
Verlach and I were sharing a quiet moment, just the two of us in the hallway.
“I think she likes me, Herb.”
Verlach said nothing. Even in the best of times, he didn’t always know what to make of me.
“Yeah,” I said, “you got it. I think she likes me in that way. It just comes across as pure, white-hot hatred.”
“Well, things are a little tense here.”
“Really? No.”
Verlach regarded me through the respirator and face shield. “Gary Hammil I don’t know. But I’ve known Jean Madison for years. She’s a good doctor—damn good infectious disease doctor—good epidemiologist—”
“And she’s still ticked that her surveillance program got slammed by Public Health. She’s still annoyed they brought you and me in.”
“That might be true.”
“It is true. And this new guy, Hammil, says that I need to grow up? I’m an emotional Methuselah compared to her. Jesus.”
“Okay, okay, you might be right, but try to see it from her side. She’s been here for two decades. At this hospital. She’s seen the assaults on its reputation, its finances, its medical staff. But it stays alive. To the point where the mere existence of this place irritates people. Everyone’s on the sidelines waiting for a slipup.”
“But dealing with this like it’s a case of the sniffles is a slipup. Am I wrong here? Isn’t hemorrhagic fever on the differential?”
“We don’t know.”
“Come on, purpuric rash? The bleeding? I haven’t even seen these women and I’m thinking—”
“We don’t know anything yet.”
“But even if we’re thinking about it, they—” I waved my hand toward the closed door. “This is bullshit.”
“Don’t sweat it.”
“I am sweating it. They should be sweating it. This is crazy, Herb. They should shut down the wing. They should be kissing my ass—and your ass—asking for help. When do you think was the last time they saw Lassa fever here?”
“I don’t—”
“Machupo? CCHR? Junin? Rift Valley—”
“I get the point.”
“I know half a dozen people who’ve seen one of these in the last year.” Gradually, I was able to get myself under control. “Come on. At least they should shut down the floor. Even with the isolation, I can’t believe they still have patients up here. I can’t believe it didn’t even come up. You should shut down the floor if they don’t.”
“It’s been five hours since we decided these cases might be related. All things considered, I think the hospital’s doing an adequate job.”
“Adequate? And that’s enough?”
“Are you trying to tell me my job, Dr. McCormick?” Verlach glared at me until I looked away. “This isn’t a textbook. And not everything happens as fast as you’d like.” Even through the face mask, I could see he was very tired. Tired and anxious. “Still, you’re right. You are correct.” He sighed. “I’ve been in public health for seven years. Probably a hundred outbreaks in that time. I even handled a case in which a pissed-off waiter spread salmonella in the salad bar of the restaurant that fired him. But nothing quite like this,” he said. “I’ll suggest to Jean that she consider making an official request for help, though I can guarantee you she won’t request it from you.”
“Come on. I’m expecting to get it with a box of chocolates, maybe on the back of a boudoir photo—”
“Nate—”
“Look, I don’t care whether she asks me or not. I care about keeping these girls alive. I care about nobody else getting sick.”
“I know. But try to calm down about that.”
We were silent for a moment. Then he said, “Look on the bright side: if you’re going to get sick, Baltimore is the best place in the world to do it.” That was a commonly held belief in this city and, indeed, elsewhere; I wondered what the folks in Boston would have to say about that. “Anyway,” Verlach said, “I’m going to suggest they close down M-2.”
“‘Suggest?’”
“Try to pick up on subtleties, Dr. McCormick. M-2 will be shut down.”
Verlach walked into the vestibule, leaving me alone for a moment
to contemplate what, exactly, was going on. Not to be arrogant, but I’m a smart guy. I understand the way the human body works, I understand the way microbes attack it, I’m even beginning to understand how bugs work their way through a population. But people, I do not understand. Their motivations and hidden agendas. The events of that day and the days following would show me just how severe a liability that is.
I walked into the vestibule, where Verlach was stripping off his protective gear.
“If we’re investigating this thing,” I said, “I thought we should begin by examining the women. Talking to them. I haven’t even seen them yet.”
“Work on that memory. You have a presentation in ten minutes.”
Not wanting to touch the outside door handle with gloves that had been in the quarantine, I stripped off my gloves and put on a new pair.
“What are you doing?” Verlach asked.
“I’m going to look at the patients. I need to see what the hell I’m presenting.”
“Your meeting, Dr. McCormick—”
“—can wait a few minutes,” I said as I opened the door. “Tell them I’ll be there when I get there.”
CHAPTER 4
As a kid, I always wanted to be a bruiser, a tough, a real crusher, which made the verbal sparring with Jean Madison kind of ironic when you think about it. Or maybe it made perfect sense. Anyway, my ambitions as a twelve-year-old were more or less dashed by a delayed puberty and by a thrashing I got in the seventh grade from a budding sociopath named Chad Pershing. All those sit-ups and push-ups failed to help me against Chad, a hormone freak who had started to shave at age ten. The details aren’t important; the upshot is: it was then that I decided the fate of Nathaniel McCormick lay less with the Joe Fraziers of the world and more with the Albert Schweitzers. If nothing else, I found it hard to believe that any member of the National Academy of Sciences would ever be able to kick my ass as thoroughly as Chad.
An uneventful but relatively productive high school career led me to Penn State for college. I took my degree in biochemistry, rode the coattails of some pretty important scientists doing some pretty boring research, and, by the end of my stint in State College, I had a broad range of medical schools from which to choose. Albert Schweitzer indeed. I ended up in California, at a university nicknamed The Farm, lodged in the bowels of Silicon Valley just south of San Francisco, in their MD-PhD program. At the end of seven years, I would have my medical degree and my PhD. I chose to take a doctorate in microbiology.
But I never got either degree in California. In fact, I was just about halfway through when they kicked me out. Which is how I ended up at the University of Maryland to finish out my MD. Which may be one reason CDC put me back in Baltimore at St. Raphe’s. Which is why I was in a grim cubicle of a room, looking down at the infirm Helen Jones.
She grunted when she noticed me, eyes rolling toward me for a moment, then back to the ceiling.
“Hello, Ms. Jones,” I said. “I’m Dr. McCormick.”
She didn’t say anything.
I walked to the bed. “Hi,” I said. Again she didn’t respond. She just blinked a few times, tears dribbling slowly from the sides of her eyes.
One of the first things you learn when you start to see patients is how to identify the truly sick. Contrary to how it sounds, this is not always easy. Is the guy who just staggered into your emergency room having a heart attack, or is it a nasty case of gas? The distinctions are often surprisingly subtle. But after a few years with the unwell, you can ride on a subway and peg those fighting congestive heart failure, emphysema, whatever.
Helen Jones’s current state was not subtle, and it didn’t take a doctor to realize how much pain she was in. How much she hurt. Worn as it may sound, disease is terrible. Really. And it’s not a fucking abstraction; screw those who try to put it in context with their “circle of life and death” platitudes. I got into this business to disrupt the damned circle.
I put my hand on Helen’s shoulder. “It’s going to be okay,” I said, and hoped I wasn’t lying to her.
The room was small, about ten by ten, and crammed full of monitors, IV stands. According to Verlach, Helen had been extubated earlier that day, but the medical team had left the ventilator in the room in case they needed it again.
This was probably a violation of some protocol—ventilators were normally used only in the intensive care units—but outbreaks of strange, hot diseases were protocol-busting events. To me, it was all very well and good that Helen Jones wasn’t down in the ICU, sharing virus with the other super-sick.
I kept my hand on her shoulder for a moment, then gave a little squeeze before going to the foot of the bed to the medical charts there.
“Ms. Jones,” I said, “I work for the Centers for Disease Control. We’re going to try to find out what happened to you. We’re going to make sure you get better.” I waited for a response, but she just continued looking at the beige ceiling. “I’m going to examine you, okay? This will be quick.”
The exam. Helen Jones, though supposedly recovering from her illness, looked like a person about to expire at any moment. Neck palpation revealed significant cervical lymphadenopathy. Hell, I didn’t need to palpate to notice it; the lymph nodes in her neck were so swollen it looked as if someone had sewn a bunch of marbles under the skin. She was jaundiced—her skin a nasty yellow, the whites of her eyes the color of urine—either the result of the disease ripping through her liver, or from her body dealing with too much bleeding. There was a penlight on the cart next to the bed. I took it.
“Open your mouth.” She didn’t.
Gently, I put my fingers on the lower jaw and pulled down, shined the light inside.
The mucosa of her mouth was polka-dotted with brown blotches of different sizes, as if it had been blasted with a shotgun. Her gums themselves were almost completely discolored. But though it looked bad, it showed she was healing. If the sickness had been fulminant, the spots would have been bright red. As it was, the blood had clotted, turned brown, and her body had begun to reabsorb it.
“I’m going to pull down your gown, okay?” The tears still dribbled, but Helen Jones nodded, almost imperceptibly. “You’re doing great, Helen,” I told her.
I pulled her hospital gown to about midabdomen. There were patches of gauze everywhere—under her arms, on her breasts, on her belly. I took a corner of one of the bandages near her armpit and lifted it, revealing a large ulcerated area that had begun to scab. The skin, it appeared, had simply slipped away, leaving a denuded patch underneath. The amount of Helen’s body that had suffered the insult—the surface area that had sloughed and scabbed—was impressive. As horrible as this thing was, as brightly drawn as the battle line was between me and it, I had to respect what it could do. Its power and its idiosyncrasies. I noted that the infection had spared much of her face.
As I reattached the bandage, Helen sighed, which launched a spasm of coughing, a heavy, gurgling sound. Something came into her mouth. Weakly, she tried to reach for the tissues next to the bed.
“Here,” I said. I took a tissue and pressed it to her mouth. Into it, she spat a gob of phlegm the color and consistency of currant jelly. She’d been hemorrhaging in her lungs. Now, as her body began to win against the infection, the blood had coagulated and she was able to bring it up. I told her she was doing well.
I dropped the tissue into the wastebasket and noticed, as I did so, that the floor was littered with tissues, each one looking like a flower, a spot of red surrounded by a halo of white.
CHAPTER 5
I walked quickly toward the conference room on M-2, dodging gurneys—some filled, some empty—being wheeled to different parts of the hospital. I guessed Verlach had had his conversation with Madison and Hammil about shutting down the floor, and I guessed that conversation had gone well. Or, at least, it had gone quickly.
In any case, I was happy that patients were being kept from any chance encounter with our vicious little disease.
Fifteen
heads swiveled when I opened the door to the conference room. Not Verlach’s, though. He sat hunched over a sheaf of files, scratching absently at his balding head. Jean Madison made a show of looking at her watch and looking at me. I smiled at her, then glanced around the room to see who was there: all the internal medicine residents, most of the attendings, two nurses, and a couple of people who had the officious look of administrators.
The speaker, the chief resident in internal medicine, stood in front of a whiteboard, medical charts spread in front of her. She paused as I found a seat next to Verlach.
Jean Madison, whose short salt-and-pepper hair was gelled to the tensile strength of Kevlar, waved her hand at me and said, “For those of you who don’t know him, Dr. McCormick of the CDC.”
Normally, with such a fab intro as that, I’d launch into my soft-shoe routine. Considering the circumstance, I settled for a hello.
“Evidently, timeliness isn’t taught in Atla—”
“Jean—” Gary Hammil touched Madison’s arm.
“Go on, Dr. Singh,” Madison said tartly.
The chief resident continued with her presentation of Helen Jones. The medical history was pretty much the same as I’d gotten from Verlach earlier that day—the flulike prodrome, the hemorrhaging a day later. Social history was a surprise, though. It seemed that Helen Jones never traveled—never out of the Baltimore area in her thirty-one years. This was something of a setback; Verlach and I would have loved to hear that Ms. Jones had just returned from Colombia or the Congo. This would have narrowed our list of potential nasties quite a bit.
But, as I said, Helen Jones had never been far from what was once officially dubbed, oddly, “The City That Reads.” And, as it turned out, Helen Jones probably didn’t.
“She lives in a group home for the mentally handicapped, a place called Open Arms,” Dr. Singh said.
So Helen Jones is slow, I thought. Interesting.
Dr. Singh went on to describe Helen Jones’s alcohol, drug, and tobacco history, which was negative. The history dragged on as Dr. Singh gave us enough detail to pack a Conan Doyle story. Though I had to admire her thoroughness, it was not serving us well at that point.
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