Outbreak

by Robin Cook

  The house itself was a three-story Victorian affair with an octagonal tower dominating the right front corner. A large porch, defined by complicated gingerbread trim, started at the tower, extended along the front of the house and swept around the left side. Above the double-doored front entrance and resting on the roof of the porch was a circular balcony roofed with a cone that complemented the one on top of the tower.

  The scene looked festive enough. Every window in the house blazed with light. Marissa drove around to the left, following Ralph’s instructions. She thought that she was a little late, but there were no other cars.

  As she passed the house, she glanced up at the fire escape coming down from the third floor. She’d noticed it one night when Ralph had stopped to pick up his forgotten beeper. He’d explained that the previous owner had made servants’ quarters up there, and the city building department had forced him to add the fire escape. The black iron stood out grotesquely against the white wood.

  Marissa parked in front of the garage, whose complicated trim matched that of the house. She knocked on the back door, which was in a modern wing that could not be seen from the front. No one seemed to hear her. Looking through the window, she could see a lot of activity in the kitchen. Deciding against trying the door to see if it was unlocked, she walked around to the front of the house and rang the bell. Ralph opened the door immediately and greeted her with a big hug.

  “Thanks for coming over early,” he said, helping her off with her coat.

  “Early? I thought I was late.”

  “No, not at all,” said Ralph. “The guests aren’t supposed to be here until eight-thirty.” He hung her coat in the hall closet.

  Marissa was surprised to see that Ralph was dressed in a tuxedo. Although she’d acknowledged how handsome he looked, she was disconcerted.

  “I hope I’m dressed appropriately,” she said. “You didn’t mention that this was a formal affair.”

  “You look stunning, as always. I just like an excuse to wear my tux. Come, let me show you around.”

  Marissa followed, thinking again that Ralph looked the quintessential physician: strong, sympathetic features and hair graying in just the right places. The two walked into the parlor, Ralph leading the way. The decor was attractive but somewhat sterile. A maid in a black uniform was putting out hors d’oeuvres. “We’ll begin in here. The drinks will be made at the bar in the living room,” Ralph said.

  He opened a pair of sliding-panel doors, and they stepped into the living room. A bar was to the left. A young man in a red vest was busily polishing the glassware. Beyond the living room, through an arch, was the formal dining room. Marissa could see that the table was laid for at least a dozen people.

  She followed Ralph through the dining room and out into the new wing, which contained a family room and a large modern kitchen. The dinner party was being catered, and three or four people were busy with the preparations.

  After being reassured that everything was under control, Ralph lead Marissa back to the parlor and explained that he’d asked her to come over early in hopes that she’d act as hostess. A little surprised—after all, she’d only been out with Ralph five or six times—Marissa agreed.

  The doorbell rang. The first guests had arrived.

  Unfortunately, Marissa had never been good at keeping track of people’s names, but she remembered a Dr. and Mrs. Hayward because of his astonishingly silver hair. Then there was a Dr. and Mrs. Jackson, she sporting a diamond the size of a golf ball. The only other names Marissa recalled afterward were Dr. and Dr. Sandberg, both psychiatrists.

  Making an attempt at small talk, Marissa was awed by the furs and jewels. These people were not small-town practitioners.

  When almost everyone was standing in the living room with a drink in hand, the doorbell sounded again. Ralph was not in sight, so Marissa opened the door. To her utter surprise she recognized Dr. Cyrill Dubchek, her boss at the Special Pathogens Branch of the Department of Virology.

  “Hello, Dr. Blumenthal,” said Dubchek comfortably, taking Marissa’s presence in stride.

  Marissa was visibly flustered. She’d not expected anyone from the CDC. Dubchek handed his coat to the maid, revealing a dark blue Italian-tailored suit. He was a striking man with coal black, intelligent eyes and an olive complexion. His features were sharp and aristocratic. Running a hand through his hair, which was brushed straight back from his forehead, he smiled. “We meet again.”

  Marissa weakly returned the smile and nodded toward the living room. “The bar is in there.”

  “Where’s Ralph?” asked Dubchek, glancing into the crowded living room.

  “Probably in the kitchen,” said Marissa.

  Dubchek nodded, and moved off as the doorbell rang again. This time Marissa was even more flabbergasted. Standing before her was Tad Schockley!

  “Marissa!” said Tad, genuinely surprised.

  Marissa recovered and allowed Tad to enter. While she took his coat, she asked, “How do you know Dr. Hempston?”

  “Just from meetings. I was surprised when I got an invitation in the mail.” Tad smiled. “But who am I to turn down a free meal, on my salary?”

  “Did you know that Dubchek was coming?” asked Marissa. Her tone was almost accusing.

  Tad shook his head. “But what difference does it make?” He looked into the dining room and then up the main staircase. “Beautiful house. Wow!”

  Marissa grinned in spite of herself. Tad, with his short sandy hair and fresh complexion, looked too young to be a Ph.D. He was dressed in a corduroy jacket, a woven tie and gray flannels so worn, they might as well have been jeans.

  “Hey,” he said. “How do you know Dr. Hempston?”

  “He’s just a friend,” said Marissa evasively, gesturing for Tad to head into the living room for a drink.

  Once all the guests had arrived, Marissa felt free to move away from the front door. At the bar, she got herself a glass of white wine and tried to mingle. Just before the group was summoned into the dining room, she found herself in a conversation with Dr. Sandberg and Dr. and Mrs. Jackson.

  “Welcome to Atlanta, young lady,” said Dr. Sandberg.

  “Thank you,” said Marissa, trying not to gawk at Mrs. Jackson’s ring.

  “How is it you happened to come to the CDC?” asked Dr. Jackson. His voice was deep and resonant. He not only looked like Charlton Heston; he actually sounded as if he could play Ben Hur.

  Looking into the man’s deep blue eyes, she wondered how to answer his seemingly sincere question. She certainly wasn’t going to mention anything about her former lover’s flight to L.A. and her need for a change. That wasn’t the kind of commitment people expected at the CDC. “I’ve always had an interest in public health.” That was a little white lie. “I’ve always been fascinated by stories of medical detective work.” She smiled. At least that was the truth. “I guess I got tired of looking up runny noses and into draining ears.”

  “Trained in pediatrics,” said Dr. Sandberg. It was a statement, not a question.

  “Children’s Hospital in Boston,” said Marissa. She always felt a little ill at ease talking with psychiatrists. She couldn’t help but wonder if they could analyze her motives better than she could herself. She knew that part of the reason she had gone into medicine was to enable her to compete with her brothers in their relationships with their father.

  “How do you feel about clinical medicine?” asked Dr. Jackson. “Were you ever interested in practicing?”

  “Well, certainly,” replied Marissa.

  “How?” continued Dr. Jackson, unknowingly making Marissa feel progressively uneasy. “Did you see yourself solo, in a group, or in a clinic?”

  “Dinner is served,” called Ralph over the din of conversation.

  Marissa felt relieved as Dr. Jackson and Dr. Sandberg turned to find their wives. For a moment she had felt as if she were being interrogated.

  In the dining room Marissa discovered that Ralph had seated himself
at one end of the table and had placed her at the other. To her immediate right was Dr. Jackson, who thankfully forgot about his questions concerning clinical medicine. To her left was the silver-haired Dr. Hayward.

  As the meal progressed, it became even clearer that Marissa was dining with the cream of Atlanta’s medical community. These were not just doctors; they were the most successful private practitioners in the city. The only exceptions to this were Cyrill Dubchek, Tad and herself.

  After several glasses of good wine, Marissa was more talkative than normal. She felt a twinge of embarrassment when she realized that the entire table was listening to her description of her childhood in Virginia. She told herself to shut up and smile, and she was pleased when the conversation switched to the sorry state of American medicine and how prepaid health-care groups were eroding the foundations of private practice. Remembering the furs and jewels, Marissa didn’t feel that those present were suffering too much.

  “How about the CDC?” asked Dr. Hayward, looking across at Cyrill. “Have you been experiencing budgetary constraints?”

  Cyrill laughed cynically, his smile forming deep creases in his cheeks. “Every year we have to do battle with the Office of Management and Budget as well as the House Appropriations Committee. We’ve lost five hundred positions due to budgetary cuts.”

  Dr. Jackson cleared his throat: “What if there were a serious outbreak of influenza like the pandemic of 1917-1918. Assuming your department would be involved, do you have the manpower for such an eventuality?”

  Cyrill shrugged. “It depends on a lot of variables. If the strain doesn’t mutate its surface antigens and we can grow it readily in tissue culture, we could develop a vaccine quite quickly. How quickly, I’m not sure. Tad?”

  “A month or so,” said Tad, “if we were lucky. More time to produce enough to make a significant difference.”

  “Reminds me of the swine flu fiasco a few years ago,” interjected Dr. Hayward.

  “That wasn’t the CDC’s fault,” said Cyrill defensively. “There was no doubt about the strain that appeared at Fort Dix. Why it didn’t spread is anybody’s guess.”

  Marissa felt a hand on her shoulder. Turning, she found herself looking at one of the black-dressed waitresses.

  “Dr. Blumenthal?” whispered the girl.

  “Yes.”

  “There is a phone call for you.”

  Marissa glanced down the table at Ralph, but he was busy talking with Mrs. Jackson. She excused herself and followed the girl to the kitchen. Then it dawned on her, and she felt a stirring of fear, like the first time she had been called at night as an intern: It had to be the CDC. After all, she was on call and she’d dutifully left Ralph’s number. No one else knew she was there.

  “Dr. Blumenthal?” asked the CDC operator, when Marissa picked up the phone.

  The call was switched to the duty officer. “Congratulations,” he said jovially. “There has been an epidemic aid request. We had a call from the California State Epidemiologist, who would like CDC help on a problem in L.A. It’s an outbreak of unknown but apparently serious illness in a hospital called the Richter Clinic. We’ve gone ahead and made a reservation for you on Delta’s flight to the coast that leaves at 1:10 A.M. We’ve arranged hotel accommodations at a place called the Tropic Motel. Sounds divine. Anyway, good luck!”

  Replacing the receiver, Marissa left her hand on the phone for a moment while she caught her breath. She didn’t feel prepared at all. Those poor, unsuspecting people in California had called the CDC expecting to get an epidemiologic expert, and instead, they were going to get her, Marissa Blumenthal. All five feet of her. She made her way back to the dining room to excuse herself and say good-bye.

  2

  January 21

  BY THE TIME MARISSA had gotten her suitcase from the baggage carousel, waited for the rent-a-car van, gotten the rent-a-car (the first one wouldn’t start), and had somehow managed to find the Tropic Motel, the sky had begun to lighten.

  As she signed in, she couldn’t help thinking of Roger. But she wouldn’t call. She’d promised herself that much several times on the flight.

  The motel was depressing, but it didn’t matter. Marissa didn’t think she’d be spending much time there. She washed her hands and face, combed her hair and replaced her barrette. With no other plausible reason for delay, she returned to the rent-a-car and set out for the Richter Clinic. The palms of her hands were damp against the steering wheel.

  The clinic was conveniently situated on a wide thoroughfare. There were few cars at that time of morning. Marissa pulled into a parking garage, took a ticket and found a spot near the entrance. The entire structure was modern, including the garage, the clinic, and what Marissa guessed was the hospital, which appeared to be seven stories tall. Getting out of the car, she stretched, then lifted out her briefcase. In it were her class notes from the epidemiology portion of the introductory course—as if that would be any help—a note pad, pencils, a small textbook on diagnostic virology, an extra lipstick and a pack of chewing gum. What a joke.

  Once inside, Marissa noted the familiar hospital odor of disinfectant—a smell that somehow calmed her and made her feel instantly at home. There was an information booth, but it was empty. She asked a maintenance man mopping the floor how to get to the hospital wing, and he pointed to a red stripe on the floor. Marissa followed it to the emergency room. There was little activity there, with few patients in the waiting room and only two nurses behind the main desk. Marissa sought out the on-call doctor and explained who she was.

  “Oh, great!” said the ER doctor enthusiastically. “Are we glad you’re here! Dr. Navarre has been waiting all night for you. Let me get him.”

  Marissa absentmindedly played with some paper clips. When she looked up, she realized the two nurses were staring at her. She smiled and they smiled back.

  “Can I get you some coffee?” asked the taller of the two.

  “That would be nice,” said Marissa. In addition to her basic anxiety, she was feeling the effects of only two hours of fitful sleep on the flight from Atlanta.

  Sipping the hot liquid, Marissa recalled the Berton Roueche medical detective stories in The New Yorker. She wished that she could be involved in a case like the one solved by John Snow, the father of modern epidemiology: A London cholera epidemic was aborted when Snow deductively isolated the problem to a particular London water pump. The real beauty of Snow’s work was that he did it before the germ theory of disease was accepted. Wouldn’t it be wonderful to be involved in such a clear-cut situation?

  The door to the on-call room opened, and a handsome, black-haired man appeared. Blinking in the bright ER light, he came directly toward Marissa. The corners of his mouth pulled up in a big smile. “Dr. Blumenthal, we are so glad to see you. You have no idea.”

  As they shook hands, Dr. Navarre gazed down at Marissa. Standing next to her, he was momentarily taken aback by her diminutive size and youthful appearance. To be polite, he inquired about her flight and asked if she was hungry.

  “I think it would be best to get right down to business,” said Marissa.

  Dr. Navarre readily agreed. As he led Marissa to the hospital conference room, he introduced himself as chief of the department of medicine. This news didn’t help Marissa’s confidence. She recognized that Dr. Navarre undoubtedly knew a hundred times more than she about infectious disease.

  Motioning for Marissa to sit at the round conference table, Dr. Navarre picked up the phone and dialed. While the call was going through, he explained that Dr. Spenser Cox, the State Epidemiologist was extremely eager to talk to Marissa the moment she arrived.

  Wonderful, thought Marissa, forcing a weak smile.

  Dr. Cox sounded equally as happy as Dr. Navarre that Marissa was there. He explained to her that unfortunately he was currently embroiled in a problem in the San Francisco Bay area involving an outbreak of hepatitis B that they thought could be related to AIDS.

  “I assume,” continued
Dr. Cox, “that Dr. Navarre has told you that the problem at the Richter Clinic currently involves only seven patients.”

  “He hasn’t told me anything yet,” said Marissa.

  “I’m sure he is just about to,” said Dr. Cox. “Up here, we have almost five hundred cases of hepatitis B, so you can understand why I can’t come down there immediately.”

  “Of course,” said Marissa.

  “Good luck,” said Dr. Cox. “By the way, how long have you been with the CDC?”

  “Not that long,” admitted Marissa.

  There was a short pause. “Well, keep me informed,” said Dr. Cox.

  Marissa handed the receiver back to Dr. Navarre, who hung up. “Let me bring you up to date,” he said, switching to a standard medical monotone as he pulled some three-by-five cards from his pocket. “We have seven cases of an undiagnosed, but obviously severe, febrile illness characterized by prostration and multi-system involvement. The first patient to be hospitalized happens to be one of the cofounders of the clinic, Dr. Richter himself. The next, a woman from the medical records department.” Dr. Navarre began placing his three-by-five cards on the table. Each one represented a patient. He organized them in the order in which the cases had presented themselves.

  Discreetly snapping open her briefcase without allowing Dr. Navarre to see what it contained, Marissa extracted her note pad and a pencil. Her mind raced back to the courses she’d recently completed, remembering that she needed to break the information down into understandable categories. First the illness: Was it really something new? Did a problem really exist? That was the province of the simple 2 × 2 table and some rudimentary statistics. Marissa knew she had to characterize the illness even if she couldn’t make a specific diagnosis. The next step would be to determine host factors of the victims, such as age, sex, health, eating habits, hobbies, etc., then to determine time, place and circumstances in which each patient displayed initial symptoms, in order to learn what elements of commonality existed. Then there would be the question of transmission of the illness, which might lead to the infectious agent. Finally, the host or reservoir would have to be irradicated. It sounded so easy, but Marissa knew it would be a difficult problem, even for someone as experienced as Dubchek.