One way to understand viruses is to think about them as biological machines. A virus is a wet nanomachine, a tiny, complicated, slightly fuzzy mechanism, which is rubbery, flexible, wobbly, and often a little bit imprecise in its operation—a microscopic nugget of squishy parts. Viruses are subtle, logical, tricky, reactive, devious, opportunistic. They are constantly evolving, their forms steadily changing as time passes. Like all kinds of life, viruses possess a relentless drive to reproduce themselves so that they can persist through time.
When a virus starts copying itself strongly and rapidly in a host, the process is called virus amplification. As a virus amplifies itself in its host, the host, a living organism, can be destroyed. Viruses are the undead of the living world, the zombies of deep time. Nobody knows the origin of viruses—how they came into existence or when they appeared in the history of life on earth. Viruses may be examples or relics of life forms that operated at the dawn of life. Viruses may have come into existence with the first stirrings of life on the planet, roughly four billion years ago. Or they may have arisen after life started, during the time when single-celled bacteria had already come into existence—nobody knows.
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As for the possibility that a virus might be amplifying itself in people at the mission, J. J. Muyembé thought that he and Dr. Omombo could be seeing an explosive outbreak of yellow fever. Yellow fever, a severe and sometimes fatal disease caused by the yellow fever virus, has a high fatality rate. The fatal form of the disease is known as fulminating visceral yellow fever. A person dying of yellow fever has a high fever, excruciating abdominal pain, and can have black vomit. The virus, as Muyembé well knew, is transmitted from person to person through the bites of mosquitoes. The mosquito, in turn, has caught the yellow fever virus by biting a person who is infected with it. Yellow fever tends to erupt in small communities in the tropics, places like Yambuku, where the virus can amplify itself in the local population like a fire going out of control.
Or, he wondered, could this be a fulminating outbreak of typhoid fever? Typhoid fever is a gastrointestinal infection caused by a type of bacteria—not by a virus. Typhoid fever is extremely contagious, but you can catch it only by eating food or drinking liquid that is contaminated with typhoid bacteria. You can’t catch typhoid by contact with blood or body fluids of a typhoid-infected person or by breathing the air near the person. There is extreme abdominal pain, violent, bloody diarrhea, and the bacteria can get into the bloodstream, causing septic shock and death. The victim, in septic shock, can have hemorrhages that flow from any or all of the openings of the body. Typhoid fever has a high fatality rate if it isn’t treated with antibiotics.
A good way to diagnose typhoid fever is to collect a blood sample from the sick person and place a few drops of the blood on a petri dish. If there are any typhoid bacteria in the blood, the bacteria will grow in the petri dish, forming a splotch-like colony. Therefore, Muyembé thought, he would definitely want to collect some blood samples from sick people. But he hadn’t seen any sick people. No patients to examine, no blood to collect. He and Dr. Omombo were given beds in a guesthouse, where they passed an uneventful night.
The next morning Muyembé and Omombo learned that one of the hospital’s Congolese nurses had died in her home during the night. Muyembé immediately made preparations to examine the body. A cadaver can tell you a lot about a disease. He got a blood-collection kit and some glass blood tubes from his boxes of medical supplies, then walked across a soccer field to a group of small houses where the hospital’s staff lived. The family of the dead nurse allowed him to enter their house. The house was small, clean, modest. The family had covered the deceased individual with a cloth. At last he would see the disease. Muyembé pulled back the cloth, and felt a sense of shock.
KNIFE
YAMBUKU MISSION
9 a.m., September 25, 1976
It was a young woman. He hadn’t expected to see someone so young, and he perceived her as beautiful, even in death. The sight filled him with a sense of unrecoverable loss. According to a journal left by one of the doctors who later investigated the outbreak, the young woman’s name was Amana. She had been working as a nurse’s aide, and was possibly new to her job. In the eyes of J. J. Muyembé, she was a colleague, a medical professional, cut down in the course of her work at the hospital. She was a casualty in the field of medicine, a sudden death in a remote place that could not afford to lose her. What might this young woman have accomplished if she had lived a full life? What good might she have done for her patients, what might she have become?
He bent over the body and began his examination. He saw small amounts of sticky, drying blood crusted or smeared around her nostrils and mouth. It was a sign of epistaxis—hemorrhage from the nose. What did her bloody nose mean? What about the blood on the edges of her lips? Had she been having black vomit? Could the black liquid have filled her mouth, smeared her lips, and gotten up into her nose as she vomited?
Yellow fever virus attacks the liver. As the liver fails, the eyes turn yellow or brownish. Indeed her eyes were discolored, either reddish brown or purplish. He wanted to inspect the eyes more closely. In his haste to reach the bodies he had forgotten to bring along rubber gloves. It didn’t matter, since the yellow fever virus isn’t infectious in direct contact with blood or body fluids—you can only catch yellow fever from the bite of a mosquito.
Using his bare fingertip and thumb, Muyembé lightly pinched an eyelid and rolled it back. The eyelid membranes were red. Inflamed. What did this mean? The appearance of the eyes was not inconsistent with yellow fever.
Gently he drew the legs apart and saw small amounts of blood smeared around the vagina. The blood was sticky and dark. It was hemorrhage, and it resembled the blood that was caked around the nostrils and mouth. The sight pained Jean-Jacques Muyembé beyond words. It was a terrible moment for him.
The woman had been bleeding from her natural openings. Was this typhoid? Was it visceral yellow fever? In order to diagnose yellow fever, he could take a sample of liver tissue and examine it using a microscope. If the woman had died of yellow fever, the tissue of her liver would show distinct changes, and these changes would provide a sharp diagnosis of yellow fever. Unfortunately, though, he hadn’t brought a microscope with him to Yambuku. There was no microscope at the mission hospital, at least none he knew of. Therefore he would need to bring a piece of the woman’s liver back to his lab in Kinshasa. He would have to cut into the body in order to collect a piece of the liver.
Not only had he neglected to bring rubber gloves with him, he hadn’t brought a scalpel, either. But he needed a way to obtain a sample. He was in a hurry, so rather than go back to the hospital and get a scalpel, he fished around in his pocket and brought out his pocket knife. He unfolded the blade; it seemed long enough to reach the liver.
He ran his fingertips across the right side of the cadaver’s upper abdomen, just under the rib cage, feeling the shape of the liver, and he located what he thought was probably the middle of the liver. He touched the tip of his knife to the skin at this spot, then pushed the knife straight in.
The blade sank through the skin and abdominal muscles and went into the liver. Immediately blood began pouring out of the incision around his knife. The blood flowed steadily and smoothly, without pulsation. There was no heartbeat; the blood was draining out of the body by gravity. It was good to see a large amount of blood coming out of the incision. It told him that his knife had pierced one of the major veins in the middle of the liver, and the cut vein had let loose a good gush of blood. So he seemed to be on target.
He turned the blade in a small circle, cutting a plug out of the liver. As he worked, blood continued to pour out of the hole in the skin, and it ran down the handle of his knife and began dribbling over his fingers. It had a brownish color and a slippery consistency. There were no clots in the blood. Cadaveric blood doesn’t coag
ulate. The clot-free blood covered his hand and spidered over his wrist and collected along the knob of his wrist bone. Luckily he was wearing a short-sleeved shirt, since the blood would have soaked into the cuff of a long-sleeved shirt. The blood dripped from his wrist, making dots on the floor.
Squinting, as he often did when he was concentrating, Muyembé wiggled his knife until he had gotten a piece of tissue completely detached from the liver. Working the tip of the knife, he began coaxing the piece out of the incision. He took up a red-top blood tube, removed the stopper, and placed the mouth of the tube against the incision. Then he teased the piece of liver out of the hole using his knife. The bit plopped into the tube along with some blood. He plugged the tube with the rubber stopper. Then he pulled the cloth back over the body.
His right hand and wrist were covered with cadaveric blood.
He thanked the family and offered his condolences, went outdoors and found a water pump, and washed the blood off his hand.
And then he got word that there was another nurse with the disease. She was still alive. When he visited her house, he found that she was desperately sick, near death, and she was pregnant. He wanted to get a sample of blood from a living patient, which he could analyze in his Kinshasa lab. He opened his blood kit, placed a rubber band around the woman’s arm, found a vein, inserted a blood-draw syringe, and filled a red-top tube with her blood. Afterward, he pressed a cotton ball on her arm in order to stop any bleeding from the needle puncture. But rather than stop the bleeding, the cotton ball became soaked with blood; the pregnant woman’s blood wasn’t clotting.
He had never seen a patient have an uncontrolled hemorrhage from a needle stick. This was an anomaly.
He returned to the hospital with the tube of blood from the pregnant woman and the tube holding the piece of liver. By then, word had gone around the local villages that doctors had arrived, and people had begun showing up at the hospital seeking help. Dr. Omombo had started triage—caring for as many patients as he could—and Muyembé joined him. The sick patients were being carried to the hospital on litters or on Congolese carry-chairs, or the patients were arriving seated on the backs of motorbikes, clinging to the driver.
Outdoors, in front of the hospital’s main pavilion, Muyembé began taking samples of blood from people’s arms. He filled about twenty glass tubes with blood. Some of these people, like the pregnant nurse, were hemorrhaging from the stick of a needle, and their blood wouldn’t clot. As he drew blood and tried to stanch the leaking from needle sticks, Muyembé got smears of blood on his hands. He put on rubber gloves for some of the messier blood draws, but he was in a hurry. At times he washed his hands with soap, but at other times he didn’t wash them at all.
By now it was midday. The liver and the blood samples would start decaying immediately in the tropical heat. He wanted to get these samples back to his lab in Kinshasa for analysis as soon as possible, but Kinshasa was eight hundred miles away, down the Congo River. He needed to keep the samples cold, especially the piece of liver. If the piece of liver was rotten by the time it arrived in Kinshasa, it would be useless for microscopic examination to get a diagnosis of yellow fever. But there was no ice at Yambuku Catholic Mission, no way to chill or freeze a piece of liver.
Muyembé and Omombo made plans to leave the mission by early afternoon. They would get their things and blood samples into the Land Rover and then head for Bumba Ville. There they would try to get on board a plane that could take them toward the capital. Muyembé packaged the blood tubes and the tube of liver carefully inside a box, to keep the glass from breaking.
Just as the doctors were about to leave, one of the nuns shyly approached J. J. Muyembé. She was Sister Myriam, the thin nun with a narrow face and a long, bony nose. Her given name was Louise Ecran. She had been working in the hospital as a nurse. “I have a fever and a headache,” she said quietly to Muyembé.
He asked the nun if it would be all right to give her a brief physical exam. She agreed, and they went into a private room.
FLIGHT
YAMBUKU CATHOLIC MISSION
2 p.m., September 25, 1976
Sister Myriam had undressed herself above the waist. Her arms were slender, and on her wrist she wore a small, elegant wristwatch. As he examined her, Muyembé observed a strange rash covering her breasts and torso.
The rash consisted of a carpet of red goosebumps rising out of a splotchy, speckly reddening of the skin. The red speckles or splotches were small bleeds, called petechiae, appearing beneath the skin’s surface. They were tiny star-shaped pools of blood, which were spreading from leaky blood vessels into the underlayers of the skin. The bleeds were easily visible through the nun’s translucent European skin.
Muyembé had never seen a rash like this. It was another anomaly. It now seemed to him that he was seeing a polymorphic disease. This is a disease that takes different forms in different people at different stages of the illness. A polymorphic disease is difficult to recognize because it is a shape shifter, a disease with many faces. To try to see the whole shape of the Yambuku disease was like looking at reflections of sunlight moving on restless water, and seeing only a dance of ever-changing flashes that never coalesce into an image of the sun.
Muyembé spoke to the nun gently, in French. “I think, Sister—I think that we must go to Kinshasa to get answers, because I don’t understand the nature of this disease.”
She refused to leave the mission. “I can’t go to Kinshasa with you,” she said. “If I go to Kinshasa, I will abandon my post and my work.”
She had become his patient. A patient has freedom of choice. All he could do was reason with her. “It is important that we go to Kinshasa,” he said, “because there we have laboratories, and there we can find solutions to the mystery.”
“I cannot go. The people would say I had abandoned them.”
He offered to take her to Ngaliema Hospital in Kinshasa. It was a private hospital situated in the old colonial district—the best hospital in the city. If he and the doctors at the hospital could identify the disease, then they would be able to offer treatment for it. And this would benefit all the people of Yambuku. If she let him take her to the hospital, he said, she would be continuing her medical service to her patients in Yambuku.
At this point, Sister Myriam agreed to go.
She would need to be accompanied by a female companion, in case she required intimate care during the journey. One of the nuns, Sister Edmonda, agreed to go along, and would care for Sister Myriam.
Then, just as they were about to leave, the superior of the mission, Father Augustin Sleghers, told Muyembé and Omombo that he, too, had a fever. The doctors welcomed the priest to come along. A commercial aircraft normally made a scheduled landing on the dirt airstrip at Bumba Ville three times a week. The next flight was due to land the following evening, in about thirty hours. They would try to get on that plane, assuming it arrived. The rains were making air travel uncertain.
Muyembé placed the box of sample tubes in the back of the Land Rover, the group crowded themselves into the vehicle, and they set out for Bumba Ville. The town was fifty miles away, a five-hour drive along the ornery dirt road that had brought the doctors to Yambuku. The Land Rover was now jammed with six people, two of whom were showing symptoms of the disease, Sister Myriam and Father Sleghers. In addition, there was Sister Edmonda, along with Omombo, Muyembé, and the vehicle’s driver.
Muyembé ended up seated next to Sister Myriam, pressed against her in the backseat and bumping against her as the vehicle lurched. Her fever seemed to be getting worse. He could feel heat coming off the nun’s body, and her face and arms dripped with sweat. He noticed that her strange rash was spreading, too. Now it was emerging from under the collar of her blouse and moving up her neck toward her face. Muyembé also saw that the rash was coming out from under the short sleeves of her white blouse and was spreading downward on her
bare arms. One of her arms rubbed against his bare arm, and he could feel her sweat on his skin. Sister Myriam remained stoic as they jolted down the road.
They arrived at the Catholic mission in Bumba Ville after dark. The superior of the mission, Father Carlos Rommel, welcomed the group and got them installed in rooms for the night, and the two nuns went into seclusion. The group spent the next day resting quietly at the Bumba mission. There was no ice at the mission, no way to keep the tubes of blood and the piece of liver cold. The samples were starting to decay.
The following evening, near sundown, a twin-engine turboprop Fokker Friendship, the workhorse of African skies, touched down on the Bumba airstrip. The little group climbed on board, and the doctors helped the nuns and the priest get seated. The Friendship took off and climbed over the river, and then banked toward the east, turning away from Kinshasa, away from the group’s final destination, and began following the Congo upstream into the east, along a bearing that would take the plane toward Lake Victoria and East Africa. This was the only flight out of Bumba, so the doctors had had no choice except to take it. The Friendship continued to follow the river upstream, its course bending gradually toward the southeast, while the sun fell below the horizon and the sky deepened to cobalt blue. The Congo stretched ahead of the plane, miles wide and braiding among islands, its multiple channels becoming indistinct in the rising darkness. Father Seghers and Sister Myriam were getting slowly sicker. The infectious agent was traveling on the Friendship, too. Along with the humans, it was headed ultimately for Kinshasa, a city with a population of two million, and with airline connections to cities all over the world.
Crisis in the Red Zone Page 3