“What will the Americans do? Nothing, if they do not understand what is happening. We must be subtle. They must think that they are experiencing an epidemic of natural disease. By the time they realize it is not so, we will have won. And if we are clever enough, they will never be certain how they were attacked or by whom.”
He paused, and Machdi finally said, “But if you have my papers, what more do you want of me?”
“It’s very simple, my friend.” Kassim spoke calmly now. “We will take care of the enemy. You will take care of the United States.” He waited for the small figure opposite him to respond.
Machdi started to speak. He could not.
Josef Kassim continued. He was well prepared. “You will work out the details and inform me of them within the week. By the way, you cannot destroy the cultures; we have them. If you refuse, the weapon will still be used; but proper control may not be possible. That is why we need you. As I said, we are not out to destroy the United States; we just want to hurt her enough so that she cannot interfere in our business. Do you see now how important your role is? You not only shall have given us the weapon, but you can insure that its effect will not be entirely lethal. Does that satisfy your conscience a little?”
“You are wrong,” said Machdi. “I have no idea what would happen if I infected an animal with the organism, let alone a man. What I know about this microorganism is limited to the test tube.” Machdi was now calmer. Perhaps here was his out. “In all honesty, I cannot even hazard a guess as to whether it can be controlled. If you really want to know what will happen, give me some time to find out.”
“There is no time,” shouted Kassim. “Your present knowledge of this microbe will have to be sufficient for our current needs.”
The terrorist stood up. His face suddenly became hard and his voice cold. “We have wasted enough time. To be blunt, you have no choice. You will agree to help us or…” He spread his hands. “I will leave you for a few minutes to decide.”
Alone in the room, Machdi did not for a minute doubt Kassim would carry out his unspoken threat. To refuse meant the end of his life and with it, of his work. More important, his lethal discovery would be used without any controls at all.
A week later Machdi stood before Kassim. “It is very simple. I have outlined the procedure for you in detail. It’s all in there.” The scientist pointed to the folder he had just handed over. Then he turned and left, without another word.
Machdi handed the envelope to the courier and watched him put it into the briefcase handcuffed to his wrist.
“I thought you might deliver this to a friend of mine in America. He has repeatedly asked me for a reprint of my latest article, and I would like him to have it without the usual delay of Second Class Mail. As long as you are going to Boston, I thought you might drop it off.”
He was surprised at his own cunning. A diplomatic courier would not be searched. In addition, a courier was trained not to examine the material he carried. Even if he did, he would not understand the significance of its contents.
Machdi prayed that Max Schwartz would.
“So it is done.”
The brief phone call from Kassim meant the end.
Machdi put the capsule on his tongue and swallowed a small amount of water from the paper cup that trembled in his hand. He looked around; the familiar scenes in the office where he had spent so much of his life grew dim. Even the old wooden chair with the worn straw cushion seemed to fade beneath him. Darkness came quickly. His last thoughts were of God and forgiveness.
three
Alex Kahn looked around the empty office at University Hospital where for the past six years he had worked and planned his meteoric rise to success. The early morning sunlight filtering through the window blinds made the room seem more lonely. He had come back to pick up his last few personal belongings from his desk. Then he would drive to New York.
The six years at University Hospital had passed quickly; he had been happy and productive here, but visions of fame and power had persisted. The decision to leave this large, midwestern medical center really hadn’t been a difficult one—he loved medicine and was obsessed with the idea of success in it, and the job of Chairman of the Department of Medicine at one of New York’s leading hospitals would bring him one step closer to reaching his ultimate goal.
Alex Kahn was thirty-six. He had finished college, medical school, internship, and two years of residency in internal medicine in Boston. The next three years there had been spent in training with the legendary Max Schwartz. If you finished that training with body and soul intact, you were considered a specialist in infectious diseases; but more important, you were accepted as one of “Max’s boys.” Members of this elite club were among the most respected physicians in the country, perhaps in the world. Sixty-three of the one hundred forty-six departments of infectious diseases in the medical schools of the United States were headed by members of this club.
Alex Kahn was a member in good standing. Most felt that he was the heir apparent to Max Schwartz’s throne that would be vacated in four years when the famous doctor reached sixty-five, the compulsory age for retirement in most university-associated medical schools. Everyone knew that Max would choose his own successor to the Max Schwartz Chair in Infectious Diseases. It was an endowed position; the salary of $50,000 and the Professorship were guaranteed by the friends of Max Schwartz who had been its architects. The doctor who acceded to the position would wield Max Schwartz’s power; his word and his policies would guide the specialty of Infectious Diseases in the United States. This was Alex Kahn’s ultimate goal. He knew Max would look for a successor outside of Boston; it was customary, and it was politically advantageous—no one was bypassed; no feelings were hurt; an outsider could come in and clean house as he saw fit in his own department. Thus, Alex had purposely left Boston for University Hospital as the first step to qualify for the position as Schwartz’s successor. Now New York would bring him another step closer to the throne; success there would make him the most logical choice.
During his three years with Max Schwartz, Alex had worked hard—hard to learn, hard to please his mentor, but hardest to discover the key to the great physician. Toward the end of his training, the answer became apparent. Max Schwartz was an intuitively brilliant diagnostician. He could walk into a patient’s room and ask the question everyone else had forgotten, or see what others had missed, and then put all the facts together to arrive at the correct diagnosis. In addition, he had the talent to hold an audience spellbound and to excite them to applause when he finished speaking. It was a rare mixture of vast knowledge and instantaneous recall stimulated by a keen sense of observation and a flair for showmanship.
“Alex,” Schwartz had once said, “when you have been giving Grand Rounds as long as I have, you learn to play the game. They don’t give me simple, everyday cases. So first I eliminate the common—being careful, however, to calculate the odds that they would sneak in a simple case just to fool me. But I know the common well enough to recognize it—and so do you. Once I’ve decided it is probably an uncommon case, I look for clues to help me make the diagnosis. Once I’ve made it, or think I have, I give the best goddamned discussion I can. I make it dramatic, exciting, forceful. I fill in the gaps with showmanship. A professor of Medicine must be a good showman. Then, on the outside chance I’m wrong, the audience is so overwhelmed by my presentation that they forgive me. I just make sure I’m right more often than I’m wrong.”
He was right most of the time. When you got to be a Max Schwartz, they gave you every rare and difficult case they could dig up. It also became part of the game—don’t let Max get the diagnosis. But he always did.
When Alex Kahn came to University Hospital, he carried as much of Max Schwartz with him as he could take—his teaching, his lectures, his approach to infectious diseases, his philosophy, even some of his mannerisms and jokes. He came to start a Division of Infectious Diseases where there had been none. In six years he had traine
d sixteen Fellows; he had started an Infectious Disease course for medical students, interns and residents that drew an audience from an area within a hundred mile radius; Infectious Disease Rounds excelled Medical Grand Rounds—and were better attended. Within two years, his division had added two full-time faculty members; it had become the strongest division in a strong department of medicine. At the end of three years, Alex was promoted from Assistant Professor to Associate Professor. He had published seventeen papers that bore his name as senior author, and there were fourteen more that listed him among their authors. If there was a difficult case, everyone came to him for help; and like his mentor, he slowly developed the knack for arriving at the correct diagnosis and choosing the proper therapy. As a teacher, he was superb. The medical students worshipped him and tried to emulate him. His success was rapid, complete, rewarding. The position in New York would have satisfied most men; to Alex, it was merely a stepping-stone into the shoes Max Schwartz soon would vacate.
As Alex glanced around the empty office for one last time to see if anything had been overlooked, he was interrupted by the telephone. It continued to ring, annoying him, and he remembered how he used to welcome the ringing. That same ring six years ago had meant his first consultations, his first private patients, his first invitations to speak. As he became busier, the ringing meant interruptions, more demands on his time, less time to do what he wanted to do. But he accepted it as part of the price of success. This call was to change his life.
“Damn it,” he mumbled. “It never stops.” He leaned forward in his chair to look through the door to see if his secretary was sitting at her desk. Realizing that it was too early for her to be there, he lifted the receiver.
“Dr. Kahn speaking. Can I help you?”
“Dr. Kahn, this is Roger Cullen. Sorry to bother you. I know you’re getting ready to leave, but this is important.”
Alex Kahn was not particularly fond of Roger Cullen, the Chief Medical Resident. He thought Cullen was no more than a messenger boy and hatchet man for the Chief of Medicine. Alex thought that a Chief Resident should be a physician who had seasoned medical knowledge, maturity of judgment, and the ability to represent the wishes and policies of his boss without being offensive. Cullen had none of these attributes. In addition, he was a fourth-generation alumnus of Johns Hopkins; he was not particularly fond of Jews and occasionally did not try hard enough to hide it.
“Dr. Cullen, I have left. I just stopped by to pick up a few things. If there’s an immediate problem, call Dr. Richards, the Infectious Disease Fellow. If it can wait for half an hour or so, call Dr. Perkins. He’s my successor. He should be in soon.”
“I’m sorry, Dr. Kahn. I really don’t know how to say this, but I don’t think you should leave for New York. We have a problem that’s growing by the minute and I don’t think anyone but you is capable of evaluating it.”
“Now look, Roger…” He paused. Alex was surprised that he didn’t just scream a few four-letter words and slam the phone down. But he was puzzled. Cullen was so damned polite; he was almost begging. Besides, as much as he disliked the resident, he knew Cullen knew his place. He wouldn’t be telling a division chief what he should or should not do unless there was a damned good reason.
“OK, Roger. Thirty seconds. What’s the problem?”
“Thanks, Dr. Kahn. Since midnight, we’ve been seeing a rather unusual type of pneumonia. Rapid onset. Sick for only about one or two hours, high fever, shortness of breath, dry cough, chest pain, cyanosis, and a hemorrhagic rash. On admission to the ER, sick as hell, comatose, no air moving in the chest. The chest x-ray shows pneumonia involving almost all of the lungs. There’s a high white count and severe hemolysis. Low oxygen in the blood and no response to 100 percent oxygen even by respirator. Sputum smears show what looks like staph. We’ve had no luck with large doses of any of the antibiotics we’ve tried.”
Alex Kahn leaned back in his chair. So far the problem sounded simple. He lit a cigarette and settled down to give Cullen a short step-by-step explanation of the problem in the true Max Schwartz fashion.
“The whole course seems entirely consistent with acute staphylococcal pneumonia, Roger. I’m a little surprised at the onset. Staph pneumonia is almost never primary; it’s always secondary to something else, usually a preceding viral infection of the upper respiratory tract or even viral pneumonia. These patients probably had a very mild viral infection beforehand. Because of the coma, you couldn’t get a history of it; or whoever gave you the history probably just didn’t know the patient had had an infection. Were you able to get any material from the rash for examination?”
“No.”
“Too bad. A smear of that might have shown you the bug. Good way to prove bacteria in the bloodstream. The cyanosis and the lack of oxygen are typical of overwhelming pneumonia.”
He paused to listen to the effect of his words on Roger Cullen. “Just like Max would have done,” he thought. “Make it sound so simple the listener feels like two bits.”
Alex was pleased with himself. He continued.
“Have you tried steroids? They usually help reduce the inflammation in the lungs and allow better oxygenation. Steroids also may reduce the hemolysis. It’s probably due to a staphylococcal toxin, you know.”
“We haven’t had time. They all died too quickly.”
“What do you mean ‘they all died’? How many cases have you seen since midnight?”
“Sixty-four. So far only the last three—the ones that came in about an hour ago—are still alive.”
“Sixty-four! What the hell are you doing down there? Why didn’t you call for help? Why didn’t you call Dr. Richards and have him call one of us? Where the hell is he?”
“Dr. Richards did come in, Dr. Kahn. He came in at 4 a.m. when I called him. He died two hours ago. He didn’t have a chance to call you. Dr. Brubaker also died—about 3 a.m.”
“Dr. Cullen, are you telling me that since midnight sixty-one people have died of overwhelming pneumonia? Staphylococcal pneumonia that probably isn’t even transmitted from man to man? And that every one of them became sick so quickly that it was too late for therapy? Doctor, we have had no such problem with staphylococcal pneumonia in this hospital since I came here; and that was six years ago.”
Alex Kahn realized he was screaming into the receiver. Anger had replaced reason; fear had replaced logic. He looked at his watch. It was 8 a.m.
“I’ll be right down. I want the x-rays lined up with the charts. I want to look at every damned sputum smear myself. Call Bacteriology and tell them I want to see every culture they have from every one of those patients—including Brubaker and Richards.”
“Thanks, Dr. Kahn. I really am afraid this is some wild type of epidemic. So far, I can’t figure it out. I hope you can—or we’re going to be burying a lot of people who were healthy yesterday. By the way, I’ve called the hospital administrator and informed him that we have a problem; I didn’t want to go into detail with him and start a panic. I asked him to keep all unauthorized persons out of the ER and to have everyone entering put on a mask and gown. I told him I would be discussing this with you.”
“Good judgment, Roger.” His dislike for the man decreased as his own concern mounted. “I’ll be right down.”
“An epidemic?” Alex said the word slowly to himself. “But an epidemic of this severity and virulence would be damned unusual in the United States in the 1970’s.”
Something else kept bothering him. He’d seen a lot of overwhelming staphylococcal infections, and none had ever acted like this. He’d have to look at those cultures carefully himself. Even a lab technician couldn’t mistake something else for staph sixty-four times in a row!
Alex Kahn knew he was good. Damned good. He could diagnose and treat almost anything he encountered in his daily practice—common or uncommon. He also knew where he was weak. In all the years of training and practice, one of the few entities he had never encountered was a true epidemic. He had been thr
ough influenza seasons and meningitis outbreaks; he had been involved in a cluster of cases of streptococcal infection on the delivery floor—so-called puerperal sepsis. Thirty or forty cases of he same disease had been the most he had seen at one time. What he had just heard sounded like only the beginning. He began to calculate: sixty cases in about eight hours; a hundred eighty cases in one day. The statistics staggered him, and the picture his mind was developing for him was terrifying.
He had often laughed at friends who went abroad to study infection in underdeveloped countries. “You’ll be our country’s biggest expert on Jungle Fever, but you’ll wait a long time for your first case,” he used to tell them. He truly believed that to practice in the United Sates you had to approach infectious diseases as they occurred here. Sure, a rare case or two came by, especially since the availability of air travel and the outbreak of limited wars here and there; but such cases could be looked up in textbooks. That took a trip to the library, not a trip to Timbuktu. But he had missed the point. What one learned in Timbuktu was not only how to treat Jungle Fever but how to treat a virulent communicable disease occurring in many persons at the same time with very little help available and with fewer beds and less medicine than there were patients.
For some reason, he suddenly remembered something Max Schwartz used to say. “Doc, the buck-passing stops at the Professor. When you’re it, there’s no ‘old man’ to run to for help. The final decisions become yours. It’s kind of lonely at first, but you learn. First thing you learn is to stop your own panic and to start thinking clearly—to call on every bit of knowledge and experience you’ve hoarded to make the decisions that have to be made. And finally you learn that some of your decisions will be wrong, and you’ll have to live with them. When you’ve learned all that, Doc, you’re ready to be the Professor.”
The 11th Plague Page 3
