The Rationing

by Charles Wheelan

  Only the part about acing the exam had any approximation to reality. I worked hard in the class, for a bunch of reasons, one of which was to impress Sloan. I was never going to have sex with her in the rare books section of the library if we did not at least get to the studying part. And to get there, I would have to add some value to the study sessions. I went to class. I did the reading. I even went to see the optional documentary during the X-hour. I sat next to Sloan as often as possible, while still trying to make it feel like happenstance. Along the way, something else happened: I fell in love with pathogens, with their stunning evolution and adaptation, even the most awful among them.

  I learned right before the midterm that Sloan was not taking the course for credit. We never did study together. Still, my career was launched. My path to the White House began with a drunken conversation in a fraternity basement and was nurtured by salacious thoughts of wild sex with my study buddy. Sad but true.

  6.

  “THE MARBURG VIRUS, WHICH IS CLOSELY RELATED TO THE Ebola virus, causes a hemorrhagic fever. After a brief incubation period, it attacks the body’s major organs, the spleen, the liver, the pancreas, the testicles, the eyes, the spinal cord. In some cases, the victim will hemorrhage—bleed profusely—from all of the body’s orifices. Somewhere between a quarter and ninety percent of human Marburg victims will die, and that’s when the virus reveals how beautifully adapted it is.”

  That was how Professor Richard Huke began his first lecture in Microbiology 32. He did not call roll; he did not pass out the syllabus. He just started talking about the Marburg virus. I am paraphrasing him, but I remember the details vividly. I am certain he used the word “beautiful,” because when someone describes humans bleeding out of every orifice and then goes on to speak admiringly of the organism responsible—well, that is something you remember. Huke had a point. The Marburg virus is spread through bodily fluids—blood, saliva, vomit, and so on. When humans die from Marburg, they become “disease bombs” (another Huke phrase). A single drop of blood from a Marburg-infected corpse can contain five million viruses. Remember, the victim dies bleeding from all those orifices. So his or her last act, post-death, is to infect the next of kin, like an uncapped oil well spewing viruses.

  Marburg strikes primarily in Central Africa (though it’s named for a German village where there was one outbreak, which is so sadly typical). In Central Africa, the most common funeral ritual is to wash the corpse and kiss it goodbye. The motivating belief is that the lack of a proper funeral will anger the spirit of the deceased and cause that spirit to seek vengeance. In the process of that ritual bathing, the five million Marburg viruses per drop of blood find their next victims. One has to appreciate the irony: the deceased exacts viral vengeance because his relatives do what they are supposed to do to avoid vengeance.

  When Professor Huke said the virus was “beautiful” or “beautifully adapted” or whatever the phrase, he was right. Remember, we do not even agree on whether viruses are living things or not. We do know that they exist primarily to replicate themselves; the better a virus is at replicating itself, the better its chances of surviving for another hundred million years or so. Natural selection helps organisms that help themselves. When I was later thrust abruptly into the media spotlight, my first mistake was speaking like a microbiology professor. When I described Capellaviridae as “elegant”—I was at least politic enough not to call it “beautiful”—I meant only that it was well adapted from an evolutionary standpoint. My comment was meant to underscore the scientific challenge that we faced in breaking the chain of transmission. Obviously, with the risk of a pandemic hanging over the nation, I can understand how my comment was interpreted differently. I did not mean to be callous or indifferent. I have since apologized formally, but I will repeat the essence of that statement here: I was speaking as a scientist. I was speaking about a shockingly devilish and dangerous pathogen in the same way that a detective might describe a wily serial killer. I did not “admire” this raging virus, as Home Depot Media stupidly suggested. We had our work cut out for us—that was all. I assume, given my role in stopping the epidemic and saving untold lives, I can be forgiven my poor word choice.

  7.

  PROFESSOR HUKE FASCINATED ME. FIVE MINUTES INTO THE lecture, and I was already convinced that I should take the course, whether Sloan was in it or not. “Should you be worried about Marburg?” Huke asked the class. Most of the students nodded yes, but no one raised a hand to answer. “You’re nodding ‘yes,’ ” he said, making eye contact with a guy wearing a DARTMOUTH FOOTBALL cap in the second row. “Why?”

  “Because I don’t want to bleed out of every orifice,” the guy in the football cap answered. There were titters from the class, as we each imagined bleeding to death out of our ears, nose, mouth, eyes, and asshole. Even Huke conceded with a little grin that the answer was clever, if not particularly deep.

  “Fair enough. Do you think that’s likely to happen?” Huke asked.

  “Not if I stay out of Central Africa,” Football Cap Guy said.

  “What if it spreads? There are flights from Liberia to Brussels three times a week,” Huke prodded. He let this prospect sink in, before turning in my direction. He made eye contact and took a half step forward. “Are you worried?” he asked. I was four or five rows back, usually far enough to be safe from this kind of thing. He just looked at me, not rudely, but it was clear he was going to wait for an answer. Some of the students in the rows in front of me turned and looked back.

  “Well, I wasn’t worried when I got out of bed this morning,” I said. “Now I am, I guess.” The class laughed again. Huke got the answer he was looking for.

  “You can stop worrying. For all the horror of this virus, we’re talking about a couple of hundred cases a year. Even in the places where it’s endemic, the infection rate is extremely low,” Huke explained. There was a brief clicking of keyboards as students made a note of this fact, which felt like it could turn up on the midterm.

  “What if it were used as a biological weapon?” a girl asked at the end of my row. Huke wheeled excitedly in her direction.

  “We’ve been close! The Soviets had that capacity during the Cold War. They never used biological weapons, thankfully, but they had them. So, yes, you’re correct. If the goal were to inflict mass casualties on a population in a particularly horrific way, Marburg would be a good mechanism—as would a lot of the other organisms that we’re going to talk about in this class. So does that worry you?” The question was directed back at the girl in my row. She was a soccer player, tall and tan and fit, probably in KKG or one of the other popular sororities.

  “Sure,” she answered earnestly.

  “Well, you can relax, at least about Marburg,” Huke assured her. “Transmission requires direct contact with a victim’s bodily fluids. We can contain that. The outbreaks are horrible, but then they fade away as we sequester the victims. But smallpox, now, that’s a nasty little virus, far worse than Marburg because it spreads more easily.” There were clicking keyboards around the room. This stuff would definitely be on the midterm. I was typing along with the rest . . . “an airborne virus that can be inhaled, like the flu” . . . “the more serious form of smallpox, Variola major, kills thirty or forty percent of those who become infected” . . . “black pustules on the skin.”

  Huke paused; the clicking keyboards continued for a few seconds as we caught up. Then he delivered his carefully scripted finale, the virus equivalent of that last burst of fireworks on the Fourth of July: “In the twentieth century, smallpox killed at least three hundred million people—more than the world wars, the Soviet purges, the Great Leap Forward, and just about every other man-made catastrophe combined.” He paused again. The typing stopped and most of us looked up. Then, when he had our full attention, he continued, “I was born in 1967. That year smallpox killed two million people around the world.”

  “Holy shit,” someone exclaimed up front.

  “Yes,” Huke answered. �
�That’s about right. You know what’s even crazier? Edward Jenner had invented the smallpox vaccine a hundred and fifty years earlier!” There was lots of clicking as Huke walked us through the mechanics of immunization . . . “infecting an individual with cowpox, a milder relative of the smallpox virus, causes the body to produce antibodies” . . . “wealthy countries developed mass immunization programs . . .”

  “What happened on October twenty-sixth, 1977?” Huke asked with a dramatic flourish. I had no idea. I looked around the room; apparently no one else did, either. After the suspense mounted sufficiently, he told us: “The World Health Organization diagnosed the very last naturally occurring case of smallpox in Somalia. The very last case! After that, the WHO certified the global eradication of smallpox—the first and only time that we have completely triumphed over a major contagious disease.” Huke must have given this lecture twenty-five or thirty times in his career. Still, he was not faking the excitement. He thought this stuff was so remarkably cool that we had no choice but to share his enthusiasm. A disease that could kill two million people in a single year, wiped out by human ingenuity.

  Huke walked us through the details, which felt more like an adventure story than biology. The developed countries had already eradicated the virus through immunization. That left the disease lurking in some of the poorest, most war-ravaged places on the planet. The goal was to identify outbreaks in those places and then contain them. Teams of public health experts were dispatched with radios to these forlorn outposts so they could call in any outbreaks. At the first sign of smallpox, the vaccine was rushed to the scene and anyone who had come into contact with the victim was immunized. “In some cases, guards were posted at the doors of infected households so no person could spread the disease,” Huke explained, relishing the detail. “The strategy was called surveillance and containment. And on October twenty-sixth, 1977, the very last case of smallpox on the planet was identified and isolated. That is how and why you live in a world free of that horrible disease.”

  This material would definitely be on the midterm, but almost no one was typing or writing. How can you forget something like that?

  8.

  THE PRESIDENT OF THE UNITED STATES WAS NOT A PARTICULARLY nice man. At times he could be kind of an asshole, to be honest. The curious thing is that I do not think that made him a bad president. If anything, it may be an essential characteristic for the job.

  I met the President on the first of April. I know it was April 1 because it was my thirtieth birthday. That morning I was trying to fix the power source in one of our microscopes in the lab. The phone rang in my office, which was really just a small nook with a desk in a corner of the laboratory. I did not have a secretary; no one in the laboratory did. The microscope was disassembled all over my workspace, so I let the call go. Then my cell phone rang, and I ignored that, too. I figured it was someone calling to wish me a happy birthday and I could call them back. (The good news about a birthday on April Fool’s Day is that people tend to remember.) But just a few minutes later a woman whom I recognized as the assistant to the Director walked into the lab. She looked around quickly, spotted me, and headed briskly in my direction: all business. “You need to answer your phone,” she said.

  “I was in the middle of something,” I replied. I was more puzzled than defensive. I did not get a lot of important calls and none that were time-sensitive. I was paid to do research, not talk on the phone.

  “The Director needs to see you right now,” she said.

  I felt a tinge of panic at that point, right in the pit of my stomach. Three days earlier, a college friend had sent an e-mail to my work address with a subject line that urged me to “TAKE THE TEST.” I foolishly opened it, and the link led me to an Internet slide show with twenty pairs of bare breasts. In each pair, one set of breasts was real, and one was “enhanced.” I did not even take the test—I was smart enough to know that—but as I rushed to close the screen, with two large sets of breasts plastered across the entire thirty-five-inch monitor, one of our lab assistants walked by my desk. “Nice,” she said sarcastically. I closed the window immediately, but still . . . not good. And now, with the Director’s assistant standing officiously in front of me, I thought, Very bad. Very, very bad.

  The lab is funded almost entirely by the federal government. My computer was government property. Roughly 80 percent of the scientists are men; the Director, a woman, was appointed in part to send a signal about the importance of promoting women in science. I had been to three full-day seminars on gender sensitivity in the workplace. (Everyone at the National Institutes of Health had to do this; I was not singled out for any particular behavior.) Even without the sensitivity training, I was well aware that studying real and fake boobs on a government computer with a huge monitor at a federally funded laboratory was frowned upon.

  Was it enough to get summoned to the Director’s office? Maybe. I stood there for a minute, trying to remember if I had deleted the e-mail. The servers were all backed up, so it probably did not matter anyway.

  “Hurry up. And bring your coat,” the Director’s assistant said. My coat?

  “Where are we going?” I asked.

  “I have no idea,” she answered curtly. “They just told me to find you as quickly as possible and take you to the rear entrance. The Director is going to meet you there.” At that point I knew this was not about trying to tell real boobs from fake boobs in a government laboratory. If anything, the pit in my stomach grew more intense. My chest felt tight, like someone was squeezing it from behind.

  The Director was standing next to a black Town Car in the circular drive at the back of the building. As I appeared, she opened a rear door of the car and motioned me in. I slid across the seat and she got in beside me, slamming the door. The car pulled out immediately. The Director introduced herself and offered a handshake. Obviously I knew who she was, but I appreciated the gesture. Many of the people whom I would meet in the coming days did not extend the same courtesy, including the President. Then again, I suppose it is silly for the President of the United States to introduce himself, just false modesty.

  “What can you tell me about lurking viruses?” the Director asked.

  “What would you like to know?” I asked. She had asked a broad question, the virology equivalent of asking a historian to tell you about wars in Europe. “You should read my Ph.D. dissertation. You’d be the fourth person,” I said, trying for humor.

  The Director had a nondescript black trench coat folded across her lap. She pulled a copy of my dissertation from beneath the coat. I could tell from the binding that it was the copy from our library at the lab. “I flipped through it,” she said. “You need to give me the basics.”

  “Where are we going?” I asked.

  “To the White House.”

  “Has there been some kind of attack?” I asked. Anybody in my field knew the risks of biological warfare. The public tends to freak out about nukes, but if you put some of those nasty pathogens that Huke taught us about on a simple rocket—the kind that Hamas can build in a garage—you could kill, maim, and terrify a lot of people. Pathogens are easier to acquire than nuclear weapons and far easier to move across international borders. That was one reason our laboratory had been relatively well funded over the previous decade.

  “It’s more complicated than that,” she said.

  “Every lurking virus that I’m aware of responds to Dormigen,” I offered.

  “Yeah,” she said in a strange, noncommittal kind of way.

  Only later, when I was sitting on a couch opposite the President, with a White House steward offering me coffee or water, would I understand what she meant by that.

  9.

  THE FIRST KNOWN CASE WAS IN NATICK, MASSACHUSETTS. A thirty-seven-year-old man had been shoveling after a particularly heavy snowstorm in late March. He came into the house and complained of flu-like symptoms. By midnight he was in the emergency room with a 103-degree fever that would not respond to aspirin or ibupro
fen. His white blood cell counts were elevated, but there was no obvious sign of infection or illness. At two-thirty a.m., after the fever climbed to 104, the attending physician prescribed Dormigen. The fever abated quickly and the patient was released from the hospital later that morning.

  We know about that particular case only because the ER physician did what she was supposed to do, which was report the illness and its symptoms to a central database jointly maintained by the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), my employer. True, the patient walked out of the hospital nearly recovered, and there were no recurring symptoms, but that had become a problem in the post-Dormigen world. Dormigen is effective against all known pathogens, meaning that doctors can cure a patient without having any idea what the underlying illness is.

  This is a great thing—mostly. Public health officials also recognized it as a looming problem. If Dormigen were to go the way of penicillin and just about every other breakthrough antibiotic—as will almost certainly happen, unless we can somehow stop the process of natural selection—we might have no knowledge of the illnesses that had been afflicting us. Dormigen took us to a strange place in medicine. A physician can have no idea what is wrong with a patient, and yet a ready cure is never more than a prescription away: the doctor hits a key, a CVS drone drops the medicine at your door, and the disease is beaten back—whatever it may have been. Many health care experts pointed out, half seriously, that if you showed up in an emergency room with flu-like symptoms, the guy mopping the floor in the waiting area could treat you just as effectively as any of the professionals in white coats. “Here, take Dormigen,” the janitor would offer before going back to his mopping. And it would work.