Crisis in the Red Zone

by Richard Preston

  Ruppol packed various items into his travel valise: pipe and tobacco; toothbrush; safety razor; socks. He added a bottle of Johnnie Walker Black Scotch. He thought that the surviving nuns and priests might appreciate it as a stress-reliever. He seemed quite relaxed about the mission.

  His wife, Josiane, on the other hand, had lately seemed to him un peu inquiète, a little worried. Josiane wasn’t quite as relaxed as her husband was about the virus. As she explained to him, what worried her wasn’t the virus itself. No, it was the Americans. She was Belgian, and she had a certain view of Americans. A positive view of them on the whole. Now it wasn’t that they were bad people, it was just that they were Americans. And this was a problem. Because, as everyone knew, Americans did not typically know what they were doing. She had begun to imagine that the Americans could do something idiotic with the virus and Jean-François could end up getting infected.

  A vision arose in her mind of the Americans returning her husband to her as an infected corpse. But she wouldn’t be able to see his corpse (not that she would want to see it if he had died of the virus) because the Americans would have put his body inside some sort of futuristic aluminum coffin resembling a NASA experiment, sealed with rubber gaskets in order to prevent the virus in the coffin from escaping.

  She kept her fears to herself, and kissed him and wished him bon voyage, and the children hugged him, and he backed out of the driveway in his car and drove to the military airfield.

  Noon, October 19

  Hours later, the epi team was in the air, riding in the cargo hold of a Hercules transport aircraft, which was flying at ten thousand feet above the Congo River. The members of the epi team were sitting in jump seats lined up along the windowless walls of the cargo hold. In the center of the hold, in front of them, sat a Land Rover, fueled up and ready to go. Not far from the Land Rover was a bar stocked with whisky, gin, Champagne, and a selection of aperitifs. The plane was a personal aircraft of President Mobutu. The team members were far too keyed up to have a drink.

  One of the team members was Pierre Sureau, a doctor from the Pasteur Institute. He had gotten concerned about the fact that the team hadn’t brought any biosafety gear with them. While the group was organizing itself in Kinshasa, Sureau went all over the city in a taxi looking to buy some protective equipment, but he soon discovered that Kinshasa was lamentably short of space suits. However, he did manage to buy a dozen French workman’s overalls. They were the bright-blue jumpsuits that auto mechanics in France like to wear. He also found some motorcycle goggles. Perhaps if you were a doctor wearing motorcycle goggles and a mechanic’s outfit you might impress the locals with the idea that you knew what you were doing around an extreme virus.

  The leader of the epi team was a CDC doctor named Joel Breman. During the flight he climbed into the cockpit and chatted with the pilots. It was a hot, windless day. The Congo River, miles wide and divided into multiple channels, had gone mirror smooth and reflected the sky, and stretched ahead of the plane as far as the eye could see, until it was lost in a scrim of clouds on the horizon. Joel Breman thought about what lay ahead. “I was scared out of my wits,” Breman recalled recently. “We didn’t know what we were facing. We didn’t know how it was spread or what we would see in the clinical picture.”

  Jean-François Ruppol, the team’s fixer, had little to say to anyone during the flight. His English wasn’t good. He knew how to improve a dispensary at a small hospital in the jungle. He could give people worm medicine and deliver a baby. He spoke Lingala and Kikongo, and he was good at tracking sleeping sickness. But what did he know about Level 4 pathogens that could wipe out millions? He had brought along a rectangular document case made of black leather. Inside the document case Ruppol had placed a secret weapon for fighting diseases. He hadn’t told the team what was inside his document case.

  The team planned to use the science of epidemiology as their main weapon against the virus. First they would learn the symptoms. Then they would make a case definition of the disease. That is, they would determine how to identify the disease in a patient. Then they would go around finding people with the disease, and they would try to learn how it was transmitted from person to person. Once they knew how it was transmitted, they could start tracing the spread of the virus through the human population. And when they knew who had the virus and who didn’t, they would try to block the virus’s spread by keeping infected people away from everybody else. In this way, they hoped to eradicate the virus from the human species before it expanded its foothold and became impossible to eradicate or rose into a plague. It was their job to stop the virus before it went medieval.

  “Epidemiologists are the steeplejacks of medicine,” Joel Breman said. “We’re the joiners. We’re the people who pull together the steel girders of skyscrapers. Concentration is very important. You’re focused on what you have to get done.”

  The Hercules landed at the Bumba airfield. Ruppol started the Land Rover inside the cargo hold and drove it down a ramp while a crowd of local people shouted, “Oye!”—celebrating the arrival of help. Not long afterward, the team was meeting around a coffee table with the zone commissioner, Citizen Olongo (the man who had earlier offered to liberate any prisoner who would bury the dead schoolteachers for Ruppol and his colleagues). The commissioner said that Bumba had been completely cut off by the quarantine, and it was impossible to get supplies, not even salt or bottled beer.

  Ruppol, who was sitting at the coffee table, brought out his black leather document case. He was sitting next to Joel Breman, who wondered what “the Belgian guy” was up to. As Breman later recalled, Ruppol opened the document case and flipped it upside down, and a pile of cash fell on the coffee table—bricks of Zairian notes. It was Ruppol’s secret disease-fighting weapon. “Perhaps this will help,” Ruppol said coolly to the commissioner of Bumba Zone.

  “What the hell? Qu’est-ce que vous faites?”—“What are you doing?” Joel Breman whispered to him. It was a bribe, he thought.

  Ruppol shrugged. “It’s the way things are done here.”

  Breman was shocked. “If we start doing this now, we’ll never get anything done without payoffs,” he said to Ruppol.

  This wasn’t a bribe, Ruppol explained to Breman. He never offered bribes, never. The money was cash assistance from his organization, Fometro, to an official who needed the money in order to operate his government during the crisis.

  October 20

  Next morning, the team set out for the Yambuku mission on the dirt road. When they got there, they found the nuns were in a state of deep trauma. Even so, the nuns had prepared a dinner of Flemish beef stew. They were enormously heartened when one of the team members, a Belgian named Peter Piot, spoke Flemish with them and enjoyed their stew. Dr. Ruppol brought out his bottle of Johnnie Walker Black. Father Léo, the priest who made the banana alcohol cocktails, drank half the bottle. After dinner, the team wondered where they would sleep. Any bed at the mission could be hot if an infected person had slept in it. Eventually they decided to sleep on the floor of the girls’ schoolroom. They washed the floor with bleach first, then lay down on it.

  Ruppol wanted nothing to do with sleeping on any bleached floor. He told the team that he would sleep elsewhere, and he went looking for a bed. After poking around a bit, he ended up at the deserted guest house of the mission, where he found a bed. He drew aside the mosquito net and inspected the sheets. He didn’t see any terribly large stains, so he climbed in.

  “La nuit fut calme”—“the night was calm,” Ruppol’s journal tells us. Yet there was something not quite right about the sounds of the night. The jungle was giving off its usual noises, the hoots of colobus monkeys, the low calls of nightjars, the scritching and whining of countless insects…all these were the normal sounds of nature in the central African jungle, yet there was something missing from the noise. There was a hole in the night. The sounds of nature were full and complete.
What was missing was the sound of drums.

  Ruppol had grown up in Zaire. As a boy he had gone to sleep every night with the sounds of drums coming in through the window of his bedroom. Sounds traveled farther after dark, and villagers would use drums at night to communicate over long distances. Often they drummed just to talk, connecting with friends and sharing news, the way people chat on the telephone. Since childhood, Ruppol had liked the sound of drums at night. To him the drums may have been a comforting presence, like your parents talking softly downstairs in the living room while you’re falling asleep in your bedroom. But on this night he heard only the sounds of nature, and the sounds of the human presence in the forest had been extinguished. It was as if something so terrible had happened in the forest that people couldn’t even talk about it….

  …Someone was knocking on his door. “Docteur! Come quickly please!”

  THE ZÁRATE PROCEDURE

  YAMBUKU CATHOLIC MISSION

  5 a.m., October 21, 1976

  Ruppol got out of bed when he heard the knocking. It was still dark, the hour before dawn. He opened the door and found Sister Genoveva standing there. She said that a woman in childbirth had arrived at the hospital. The situation didn’t look good.

  Ruppol threw on his clothes and got his medical bag, and followed the nun to an open area in front of the hospital, where the woman was lying on the ground on a litter, surrounded by family members. He played a flashlight over her and saw that the whites of her eyes were bright red, suffused with blood. This was a clinical sign of the virus. She was pouring with sweat, gravely sick, and had a very high fever. She was obviously near death.

  Ruppol experienced a moment of fear as he looked at the woman. She had a fever, she was at the end of her rope, he thought. There were two lives at stake here. Normally he would do an immediate C-section. Yet a pregnant woman who was infected with the unnamed virus could be extremely infective. If he cut into the mother there would be a lot of blood. And there was the case of Sister Beata, the midwife. She had caught the virus after she’d delivered babies from very sick mothers; mothers close to death.

  On the other hand, she might not have the virus. If she didn’t have the virus, he should not bring her inside the hospital and cut her skin, exposing her bloodstream to the virus. He certainly couldn’t do any surgery in the maternity ward, not with blood on the table and the bloody bandages and tampons that were scattered around the birthing room. And the operating room was just as bad.

  “The virus is all over the hospital,” he said to Sister Genoveva.

  He decided to do the surgery outdoors. But he would need an operating table. He asked Sister Genoveva if it would be possible to get a table from the kitchen or dining room and set it on a porch in the open air. While the nun hurried off, he dressed himself in surgical protection—a cotton blouse, a cap, a cloth surgical mask, latex gloves. The virus was transmitted through the liquid humors of the body. He was going to make sure that the woman’s body fluids did not have any contact with his skin or with any wet membranes of his body, particularly his eyes and mouth.

  Sister Genoveva returned with two men carrying a table. They placed it on a porch, under an electric lightbulb. The men lifted the woman up on the litter and slid her onto the table. She seemed to be in extraordinary pain. One of the men was a nurse named Sukato Mandzoba.

  The lightbulb on the ceiling wasn’t giving enough light. Ruppol asked the nun and Nurse Sukato to hold flashlights pointed at the woman’s birth area. In the beams of the flashlights he could see mucus and what might be small amounts of blood smeared around her vagina. He inserted two fingers into the birth canal and touched the woman’s dilated cervix. He could feel the baby’s buttocks or feet trapped in the neck of the cervix. The baby was in breech presentation, turned sideways, and it had gotten stuck in the birth canal.

  He decided against doing a caesarian section. The procedure would produce large amounts of blood, and the blood could be extremely infective. Furthermore, there was no general anesthetic at the hospital—another reason not to do a C-section. Finally, in Zaire, C-sections were culturally unacceptable. A woman who’d had a baby by C-section was considered to be mutilated, and she could be ostracized by her community. He decided, instead, to do a primitive surgery called the Zárate procedure. Also known as the Zárate cut, the surgery had been developed in the late 1700s in France, and had been modified in the 1920s by an Argentinian surgeon named Enrique Zárate. The Zárate procedure was no longer used in modern hospitals, but Ruppol still did the Zárate cut from time to time, when he thought a C-section would be inappropriate.

  He washed the front of the woman’s pelvis with iodine and gave her a shot of a local anesthetic directly into the surgical area. She would feel it when he made the incision, for sure she would feel it, but a local would do. He asked Sister Genoveva and Nurse Sukato to take hold of her arms and knees, and grip them tightly. When he made the Zárate cut she could thrash or struggle, and he needed to make the cut very carefully.

  The nun took hold of the woman’s arms, and Nurse Sukato grasped her knees and raised them until they were bent. Ruppol took up a scalpel in his right hand and placed his left index finger on the front of her pelvis. He moved his fingertip around slightly, feeling the structure of the bones, until he’d located a spot at the front of the pelvis called the symphysis pubis. It’s a hard spot, just above the pubic area, where the bones of the hips come together in front. The hip bones form a joint at the spot, but they don’t fuse: The hips are held together by a thick piece of cartilage at that spot.

  After he had located the spot with his finger, he told Nurse Sukato to start pulling the woman’s knees apart. Use gentle pressure on her knees, he told Sukato. Hold them tightly in case she struggles.

  Sukato started pulling on the woman’s knees, and Ruppol pushed the point of the scalpel vertically downward into the cartilage at the frontal joint of the hips, the symphysis pubis. Then he started making a cut across the cartilage, extending the cut in a vertical direction along the line between the navel and the birth opening. He stroked the blade gently, working it down into the cartilage, while blood welled out of the incision and ran down toward the birth opening. She didn’t struggle; she just wanted her baby out. He continued making light strokes with his scalpel across the cartilage. Meanwhile he listened.

  Suddenly there was a crack, like a rubber band snapping. It was the sound of the cartilage breaking apart and the bones of the pelvis opening up. The moment he heard the sound he stopped cutting into the cartilage and told Sukato to stop pulling her knees apart. He had left a small amount of cartilage in place, which held the pelvic bones loosely together, like a piece of tape. If by accident he had cut entirely through the cartilage, her pelvis would have fallen open.

  The baby had loosened. He slid his hand up through the neck of the cervix and got his hand around the back of the baby’s head, and pulled the baby out.

  The baby came out in a rush of birth fluids and mucus. Tugging on the umbilical cord, he pulled out the placenta. He cut the umbilical cord, and held up the baby and inspected it.

  It wasn’t breathing.

  Ruppol ripped off his surgical mask, bent toward the baby, and covered the baby’s mouth and nose with his mouth, and blew a puff of air into the baby’s mouth and nose. He gave several light puffs, inflating the baby’s lungs a little bit at a time. If he blew too hard he could rupture the lungs.

  Sister Genoveva and Nurse Sukato had taken a step backward and were staring at Ruppol. They saw a look of shock come into Ruppol’s face. He had suddenly realized what he was doing. But he kept his mouth pinned to the baby’s mouth. The baby’s chest rose; the lungs were inflated; and Ruppol took the baby away from his face. The baby let out a cry, exhaling Ruppol’s breath. It was alive.

  Genoveva and Sukato were staring at Ruppol in horror. His mouth, nose, and cheeks were plastered with mucus and birth fluids mix
ed with blood that had run out of the incision or had come out of the birth canal. He was quite obviously tasting the liquids in his mouth.

  “Doctor, do you know what you have done?” the nun whispered.

  “Now I know,” Ruppol answered.

  He seemed frozen in horror. The witnesses saw how his face gleamed with liquids. He kept holding the baby in front of his face and staring at it. He was following standard procedure. After resuscitating a newborn, the physician should watch the baby for three minutes. This is to make sure that the baby continues breathing on its own. If the baby’s breathing stops, the physician gives the baby more rescue breaths.

  What else could Ruppol do but watch the baby and give it more rescue breaths if needed? It was too late for the doctor to save himself. There was nothing Ruppol could do, nothing at all that would change the choice he had just made. He had done so many childbirths, he had given rescue breaths to so many infants…and in a split second he had forgotten himself and had acted out of instinct. Dr. Ruppol knew precisely what he had just done, because these words appear in his journal: “I had just condemned myself to death.”

  That morning at breakfast, Ruppol was subdued. It seems that he didn’t mention to anyone on the team what he had done. Maybe he felt embarrassed. He had given speeches all over Bumba Zone warning people not to touch anybody who had the symptoms, and then he had dived into the virus with his whole face. As for Sister Genoveva and Nurse Sukato, it seems that they maintained a discreet silence about Ruppol’s mistake.

  The international team broke up into smaller epi teams and began searching through Bumba Zone, looking for people who had symptoms of the disease. They drove in the Land Rovers to sixty-nine villages around Yambuku, asking questions, looking at people, describing the symptoms of the disease to people, gathering information. The roads between the villages were swamped with mud and almost impassable. Some villages seemed indifferent to the disease, not at all worried, while other villages were deeply frightened, and had cut themselves off from the outside world—the villagers had chopped down trees and let them fall across the road in order to stop any vehicles from getting near the village. This was reverse quarantine, in which the village cut off its contact with the outside world in order to protect itself from a spreading disease. In at least two villages, the doctors discovered houses that had been burned down with dead bodies inside them. People had died of the disease inside the houses, and members of the community had then set the houses on fire in order to incinerate the corpses. At least some of the people had followed the harshest measure of the Ancient Rule.