Panic in Level 4: Cannibals, Killer Viruses, and Other Journeys to the Edge of Science

by Richard Preston

  HALF A YEAR LATER, when the disease hunters finally explored Mbwambala, they found a small, narrow hole that G.M. had dug during one of the last days of his life. The hole went down two feet among the roots of a tree. They wondered if he had dug up something in the hole and had eaten it. It might have been a tuber or a burrowing rodent with a nest of babies, or perhaps he had found a snake or some edible grubs there. Caterpillars are also a favorite food in Congo, especially a particular caterpillar that has a hard, shiny black head and a soft body and can grow up to five inches long. People in Congo roast it over a charcoal fire. Perhaps G.M. found some unusual wild caterpillars in the leaves of a tree he had cut down and ate them. He kept a few snares and traps in Mbwambala, for catching small animals, which he brought home to his family to eat. Perhaps he’d visited his snares, perhaps not; no one knows. Perhaps an animal bit him while he was taking it out of one of his snares; no one knows. The animals that turned up in his snares were mostly wild rats, including the giant African rat, which can be the size of a small dog. Some local people claimed, afterward, that G.M. had stolen an animal from someone else’s snare.

  Later in the day, he headed farther up the creek, deeper into Mbwambala. There, he visited a couple of maize fields he was tending. He had carved these fields out of the forest. During the heat of the day, he took a nap under a small shelter in one of his fields. Perhaps he was bitten by a spider or insect while he slept in the shelter. He returned to the city at dark. He had traveled twenty miles that day.

  He would never visit the place again. Over the next few days, he began to feel unwell. He stayed home at his family compound in Kikwit. He ran a high fever; his eyes turned bright red. He got the hiccups, and they simply wouldn’t stop. His face assumed a masklike appearance. He began defecating blood into his bed. His family took him to the Kikwit General Hospital, in the center of the city, where he died on January 13, of what people in the city would later call la diarrhée rouge, the red diarrhea.

  2. Maternity Ward

  BY LATE JANUARY, three members of G.M.’s family had died of la diarrhée rouge. Ten more members of his extended family, who lived in Kikwit and in surrounding villages, also came down with it. Some of them got endless hiccups, and all of them died. They, in turn, infected more people, and they all died.

  Then it got into the Kikwit Maternity Hospital. This was a small collection of buildings in the south-central part of the city where pregnant mothers went to have their babies delivered. When a pregnant woman came down with it, the first sign was brilliant red eyes. The eyelids would eventually ooze blood, and the blood would stand on the edges of the eyelid in beaded-up droplets. The urine turned red—the kidneys were hemorrhaging; then the kidneys failed, and the person stopped urinating. The infected women in the maternity ward developed a masklike facial expression, and they became disoriented. Some had seizures. The disease was attacking the central nervous system. Some of them abruptly went blind. The skin became covered with a rash, a sea of tiny bumps, like goose bumps. The patients suffered from disseminated intravascular coagulation (DIC), in which the blood formed tiny clots throughout the body. At the same time, some of the patients were having hemorrhages, including bloody noses; in many patients, the stomach became distended and they began vomiting blood.

  The illness invariably caused pregnant mothers to abort the children they were carrying; the fetus or baby was always either born dead or died shortly after birth. None of the babies of ill mothers survived. During the delivery, the women experienced profuse, body-draining hemorrhages from the birth canal, and they died of hypovolemic shock. This is the shock that occurs when much of the blood has been drained from the body.

  The doctors and nursing staff who worked in Kikwit Maternity Hospital did the best they could, but the hospital suffered from a shortage of basic medical supplies, such as rubber gloves. The doctors thought that they were dealing with an outbreak of dysentery.

  On April 10, a medical technician who had been working with dying mothers at Kikwit Maternity Hospital came down with severe stomach pains. I will refer to him as the Maternity Technician. He went across town to the Kikwit General Hospital to get himself examined and treated. A doctor there suspected that the Maternity Technician had typhoid fever with peritonitis—a bacterial infection of the abdomen that is fatal if it isn’t treated immediately. The doctors at Kikwit General Hospital put the Maternity Technician into surgery.

  A group of Italian nuns worked in the hospital as nursing sisters. They were known as the Little Sisters of the Poor, and they came from a convent in Bergamo, Italy.

  One of the nuns, Sister Floralba Rondi, assisted two surgeons and a nursing team in the operating room on the day they operated on the Maternity Technician. The lead surgeon made a vertical cut down the center of the technician’s abdomen, opened him up, and looked into his abdominal cavity. They were expecting to see pus. Pus occurs with a bacterial infection. There was no pus; there were no bacteria. (Viruses are not bacteria.) The surgical the team took out the man’s appendix.

  The next day, however, the Maternity Technician grew worse. His abdomen became very swollen and distended. Wanting to see what was causing the distension, the doctors inserted a hypodermic syringe into his abdomen and extracted a sample. The syringe filled up with blood. The blood had a runny, homogenized appearance. It wouldn’t coagulate.

  The doctors brought him back into the operating room and opened him up through the same incision as before, in an effort to find the source of his bleeding and stop it. They couldn’t find any source for the bleeding. The blood seemed to be coming directly out of his organs, as if from a squeezed sponge. They sewed him back up. By the time the surgical team had finished the surgery, the team members were probably smeared with the Maternity Technician’s blood and probably had it all over their hands. Some or all of the team members performed the surgery without gloves, with bare hands.

  Two days later, the Maternity Technician died.

  In the next ten days or so, nearly every member of the team that had operated on the Maternity Technician also died, including Sister Floralba and two surgeons. Other medical staff who had been caring for the Maternity Technician, including Sister Dinarosa, died as well. At this point, it was clear that there was a dangerous disease loose in the hospital. The doctors wanted to get the word out and get help. There was no telephone at the hospital, but the hospital had a communication radio. Every evening at the same time, the surviving nuns sent out a radio bulletin, reporting on the events of the day, the deaths that had occurred. This message was relayed by fax every day to the convent of the Little Sisters of the Poor, in Bergamo, Italy. The nuns in Bergamo were becoming increasingly alarmed about the deaths of their sisters in Kikwit.

  As the news got out that the disease killed practically everyone who got it, the city of Kikwit went into a panic. Almost all of the patients who were in Kikwit General Hospital fled back to their homes, fearing the disease in the hospital. Some of them went to the villages surrounding Kikwit. Because of the bleeding and the high rate of mortality, the doctors began to believe that they were dealing with Ebola.

  They set up an isolation ward in Pavilion Three of the Kikwit General Hospital. They brought in thirty patients who were suffering from the red diarrhea and placed them in the beds. The mattresses soon became soaked with blood and filth, and the floors became slippery with blood.

  One of the physicians, Dr. Mpia A. Bwaka, volunteered to stay in Pavilion Three with the patients. By this time, it was fairly obvious to Dr. Bwaka that this decision meant that he would probably die. He was helped by three male nurses who also volunteered to stay with the patients, even though they knew that they would probably get the disease and die. The nurses’ names have not been recorded in the medical literature; they were local men from Kikwit who were earning next to nothing for their work. Dr. Bwaka wasn’t getting paid, either. The hospital’s staff had not received their salaries in several months; economic conditions in Congo were very bad. />
  Dr. Bwaka and the three men gathered up the hospital’s small supply of rubber gloves and took them into Pavilion Three. They wore the gloves sparingly, washed them, and reused them. They wore cloth surgical gowns and handmade masks woven locally from cotton. They slept in the pavilion with their patients. As the patients died, the corpses were left in the beds or were placed on the floor, to make room for more people being brought into Pavilion Three. By now, hundreds of people in Kikwit and the surrounding towns were dying of it. It had all come from one man who had gone into the forest in Mbwambala and come into contact with some wild creature there.

  3. Identification

  IN PAVILION THREE of the Kikwit General Hospital, Dr. Mpia Bwaka collected samples of blood from fourteen of his patients. Somebody drove the samples over the terrible road to Kinshasa. From there, the blood samples were flown to a laboratory in Belgium. The Belgian scientists, fearing that the blood might be dangerous, sent them along to the Centers for Disease Control and Prevention in Atlanta—the CDC. The fourteen tubes of blood from Pavilion Three ended up in the Biosafety Level 4 hot zone of the Special Pathogens Branch, where a researcher named Ali S. Khan, working along with several colleagues, identified Ebola virus in all fourteen of the test tubes. It was a new type of Ebola virus, and it would eventually be named Ebola Kikwit.

  As it happened, just at that time, another new type of Ebola was causing an outbreak in Ivory Coast, in West Africa. This type of the virus would eventually be named Ebola Ivory Coast. Thus two outbreaks of different types of Ebola occurred almost simultaneously in different places, which deepened the mystery over the origin of Ebola. Why and how was Ebola emerging in different places? A medical team from the World Health Organization, in Geneva, was preparing to fly to Ivory Coast, in West Africa, to investigate.

  The WHO Ebola Ivory Coast team was led by Bernard Le Guenno, a scientist from the Institut Pasteur in Paris, and by Pierre Rollin, a French virologist who was then stationed at the CDC in Atlanta. But with the large outbreak happening in Congo, which needed immediate attention, Bernard Le Guenno and Pierre Rollin were sent to Congo instead, where they joined a ten-member WHO team of doctors from France, Congo, the United States, and South Africa.

  The Ivory Coast Ebola case had occurred about a month before G.M. got sick—he was the first person known to have Ebola Kikwit. In Ivory Coast, a woman scientist from Switzerland (whose name has never been publicly disclosed) was studying a troop of wild chimpanzees in Taï National Park. The Taï Forest was one of the last pristine rain forests in West Africa. The troop of chimpanzees became infected with a mysterious disease, and many of them died. The Swiss woman, extremely concerned about her chimps, dissected one of the dead animals, trying to find out what had killed it. Soon afterward, she developed a rash and became severely ill, and she began having hemorrhages. She developed the symptoms of Ebola virus.

  For unknown reasons, Ebola had been getting into chimpanzees. Chimps and other great apes, such as bonobos and gorillas, are probably not natural hosts of Ebola virus. This is because Ebola makes the apes extremely sick—as sick as humans become with the virus. (The western gorilla is presently very threatened by Ebola virus, and many gorillas have died in Congo from outbreaks of Ebola among them. No one knows how the gorillas are getting Ebola, but some wildlife biologists fear that Ebola could help cause the western gorilla’s extinction.) The fact that Ebola is exceedingly lethal in monkeys and apes means that the natural host of Ebola is probably not a monkey or ape—those animals haven’t developed resistance to it. But somehow, the chimpanzees of the Taï Forest were coming into contact with Ebola’s host.

  The Swiss woman was flown on a commercial airliner to Switzerland for treatment. Her doctors in Switzerland did not realize that she was infected with Ebola. They suspected that the illness was dengue hemorrhagic fever, a virus carried by mosquitoes. Nevertheless, she survived, and no one else in the hospital in Switzerland got sick.

  The Taï chimps ate all sorts of things. They hunted colobus monkeys and ate them raw, tearing them apart, a bloody process. Possibly the chimps were catching Ebola from dead monkeys; the monkeys might have been catching Ebola from some other creature they were hunting.

  There was another curious case of an Ebola-like illness at the same time. A twenty-one-year-old Swedish medical student who had been traveling in Kenya returned to Sweden. He had lived for a month in the town of Kitale, which is at the base of Mount Elgon, about twenty-five miles from Kitum Cave, a site that may be a hiding place of the type of Ebola called Marburg virus. The Marburg virus may not necessarily exist all the time inside Kitum Cave. It could just as easily live in a host that occasionally visits Kitum Cave. At any rate, the Swedish medical student didn’t visit the cave during his time near Mount Elgon. Five days after his flight arrived in Sweden, he became deathly ill, and he ended up in the University Hospital in Linköping—a world-class research hospital. He was showing all the signs of African hemorrhagic fever. He began to bleed out of the openings of his body.

  A medical team at the Linköping hospital scrambled to save his life. A nurse was bending over his face when he suddenly vomited blood into the nurse’s eyes (she wasn’t wearing eye protection). In the ensuing flurry, two other members of the team accidentally stuck themselves with needles. These accidents with blood and needles did not happen because the medical workers at Linköping were incompetent; they were highly trained. The accidents happened because they rushed in to save a patient’s life, forgetful of their own safety. This is what Dr. Mpia Bwaka and his nursing team were doing at the Kikwit General Hospital. Unlike the Swedish team, however, the Congolese doctors had virtually no medical supplies, and were working in a run-down cauldron of a hospital that had been virtually abandoned by government authorities. Dr. Bwaka and his team were working literally up to their elbows in blood, black vomit, and excrement the color of beet soup. The team didn’t even have running water to rinse the floors of Pavilion Three.

  In Linköping, Sweden, the ill Swedish student survived. A team from the United States Army Medical Research Institute of Infectious Diseases, or USAMRIID, at Fort Detrick, Maryland, flew into Sweden carrying biohazard space suits and other gear, to help investigate the case. The Army team discovered that fifty-five medical personnel at the Linköping hospital had been exposed to the patient’s blood and bodily fluids. They were all at risk of being infected with the unknown infectious agent. Almost unbelievably, no one became sick, including the nurse who had got a faceful of blood. The researchers were never able to identify an infectious agent in the student’s blood. It remained a case of “suspected Marburg virus.” Despite the happy outcome in Sweden—the student and everyone else survived the incident—it showed that the best hospitals and the best medical people are still vulnerable in the face of an unidentified infectious agent that finds its way into the health-care system.

  4. Ebola Kiss

  WHILE EBOLA was breaking out in Kikwit, I spoke with a doctor named William T. Close, who had lived in Congo (then Zaire) for sixteen years. When he was in Zaire, Bill Close rebuilt and ran the Mama Yemo General Hospital, a two-thousand-bed facility in the capital. When Ebola broke out for the first time, in 1976, Close went to Zaire and helped coordinate the medical effort to deal with the virus, and advised the Zairian government. Years later, during the Ebola Kikwit outbreak, he acted as a liaison between Congolese government officials and doctors from the CDC in Atlanta.

  “In 1976, when Ebola broke out in Yambuku that first time, there was a nun, Sister Beata, who died of Ebola,” Close recalled. “There was a priest, Father Germain Lootens, who gave her the last rites as she died. She had a terrible fever, sweat was pouring down her face, and bloodstained tears were running down her face. Father Lootens took out his handkerchief and wiped the sweat from her forehead and the bloody tears from her face. Then, unthinkingly, he took the tearstained handkerchief and wiped the tears from his own face with it—he had been crying, too. A week later, he came down with Ebola,
and a week after that he was dead.”

  Now, Close had been hearing reports that some members of the medical staff of Kikwit General Hospital—Dr. Bwaka and his nurses—had continued to care for Ebola patients despite the grave risks to themselves. “Those hospital staff people have gone into that hospital to work knowing that they may die,” Close said. And the doctors and nurses in Kikwit were working without basic medical supplies. “The greatest need in Kikwit right now is for rubber aprons to protect the doctors and nurses, because the blood and vomit is soaking through their operating gowns,” he said. “This is a huge, lethal African hemorrhagic virus. We all sort of feel that Ebola comes out of its hiding place when something occasionally alters the very delicate balance of the ecosystems, in a tropical region where things grow as they would in a petri dish. But if there are lessons to be learned here, they are human lessons. This is about people doing their duty. It’s about doctors doing what has to be done, right now, without a whole lot of heroics. Have you ever been petrified with fear? Real fear? Possessed by naked fear, where you have no hope of control over your fate? If you’re a medical worker, when the die is cast, the fear goes away, and you do what you have to do—you get to work. That’s what’s happening with the medical people in that hospital right now. There are things happening in Kikwit…” He paused. “Magnificent human things…. How can I explain this? There was another incident in 1976, also in Yambuku. One of the doctors—he was a Belgian named Jean-François Ruppol—delivered a baby in the middle of it all.” Ebola has a profound effect on pregnant women: they hemorrhage profusely and abort the fetus, which itself is infected with Ebola. “There were people dying of Ebola all around in that room in the hospital, and there was a woman in childbirth. She was Dr. Ruppol’s patient, and her baby was his patient, too. The baby was stuck—too big for the birth canal.” The woman had a high fever, she was terribly ill, but her baby had to be delivered, even if it was infected with Ebola. “So he performed the Zarate procedure on her,” Close said.