Crisis in the Red Zone

by Richard Preston

  By the end of their investigations, the epi teams had visited villages in an area about sixty miles across, which had a population of 170,000 people. There were very few new cases of the disease. The virus was already almost gone. The teams discovered nine people who had the disease, five of whom died quickly. They found five other people who possibly had the disease and one person whose blood showed they’d been infected but had survived. It was clear to the investigators, after they’d driven around the villages, that the outbreak in Bumba had already nearly ended by the time the international team arrived. Something or somebody had stopped the virus.

  If the international team didn’t stop the virus, who did? And how?

  The evidence is that the people of Bumba Zone stopped the virus themselves. This happened after they knew how to identify the disease and understood how it was transmitted from person to person. Doctors Ruppol, Raffier, and Buassa played a key role in giving people this information during their earlier visit to Bumba.

  These things were very, very hard to do. The Ancient Rule went against a normal person’s instincts to protect and care for loved ones. The virus was implacable, and people had to become implacable in order to defeat it. They had to restrain themselves from giving care to sick people. They had to cut themselves off from contact with any person who looked like they might possibly have the disease. They had to stop their traditional expressions of grief for loved ones who died. The people of Bumba did these things. They ostracized the families of sick people and offered them no care. Many individuals, grieving for loved ones, seem to have ended their practice of sleeping next to and embracing the dead. In a few cases they burned houses. Above all, they stayed away from Yambuku Catholic Mission Hospital. Any sensible person could see that the disease had been centered on the hospital, and so if you didn’t want to catch it you stayed away. Jean-François Ruppol, after urging the people to do the hardest things, telling them to turn cold hearts on the sick and frail, went and did the opposite, and lost his head over a baby.

  BLEEDOUT

  KINSHASA

  October 15

  J​. J. Muyembé was the dean of the medical school, and he had a responsibility for the safety of Kinshasa, a city of two million. The case that threatened the city most was that of the twenty-three-year-old nurse at Ngaliema Hospital, Mayinga N’Seka, who had taken care of both Sister Myriam and Sister Edmonda as they died. She had gotten infected, and then, feverish, had gone around Kinshasa and had contact with many people. As Nurse Mayinga lay dying at Ngaliema Hospital, Muyembé and a team of investigators traced her contacts around the city. They followed at least a hundred people, none of whom caught the virus. All the while, Muyembé wondered if he had also caught the virus from the nun just the way Mayinga did, and that he was about to turn into another Nurse Mayinga himself—he, the dean of the medical school. Now that would really scare Kinshasa. Meanwhile Mayinga’s blood began throwing clots all through her body—the virus had triggered a generalized whole-body stroke. A South African doctor named Margaretha Isaäcson tried to save Mayinga by giving her a blood thinner, to stop the clotting, but the treatment backfired, and Mayinga went into a profuse bleedout from the intestines. She died in shock, with Dr. Isaäcson at her bedside.

  Two days before Nurse Mayinga died, some of her blood was collected in tubes, and the tubes were sent to the Special Pathogens Branch at the CDC. There, researchers put drops of Mayinga’s blood into flasks, and grew the virus that was in her bloodstream. Today, the virus is called the Mayinga isolate of Zaire ebolavirus, or simply the Mayinga. It’s a particular snippet of the changing Ebola swarm that, for a few days, replicated in Nurse Mayinga. The Mayinga is now immortal, and is stored in frozen water in tiny plastic vials that are kept in superfreezers in the Level 4 labs of the CDC. Nurse Mayinga’s place of rest seems to have been forgotten. According to one account, her remains were placed inside biohazard bags and given to her family, and her family buried her somewhere along the Congo River not far from Kinshasa, in the village where she was born.

  * * *

  —

  The death of Dr. Jean-François Ruppol, the director of the Belgian medical mission in Zaire, was first reported on October 27, 1976, on the radio in Lower Congo, the province where he had grown up and had practiced medicine for decades. Dr. Ruppol had made the ultimate sacrifice at Yambuku fighting the virus. He had gotten contaminated, and the disease had overwhelmed his body so quickly that there had been no time to evacuate him to the capital, where he might have had a chance of being saved. A large funeral would take place in Kinshasa as soon as the body was returned, and hundreds were expected to attend.

  The radio was wrong. At about two o’clock in the afternoon on October 27, Ruppol, unaware of the reports of his death, parked his car in the driveway of his house on Avenue Mfumu Lutunu. He let himself into the house quietly. The children heard him, and they raced to the door, overjoyed to see him. He dropped his travel valise and picked up the children and hugged and kissed them. Then he went into the living room and fell into a chair. He was utterly exhausted, but otherwise he felt fine.

  Josiane entered the room moments later. She already knew he was alive, and she was extremely happy about that. Now her husband was sitting in the living room with his shoes on the carpet. Her first thought was to wonder where his shoes had been. My God, she thought, he has hugged the children.

  He stood up and offered to kiss her.

  She backed away from him. “No kiss,” she said abruptly. Then she went over to the liquor cabinet and took out a bottle of Scotch. “Have a whisky first, before you kiss me.” Alcohol would disinfect his mouth, of course. She poured a large amount of Scotch into a glass and handed it to him.

  He drank the whisky immediately. He badly needed a drink.

  She poured him another. “Have two whiskies! Have three! Take the bottle outdoors and drink it all. And go take a bath.”

  He went outdoors to the patio and proceeded to disinfect himself with about three Scotches. Afterward, in the bathroom, he soaked in the tub, enjoying the pleasant sensation of being alive and at home. After a little while there was a knock on the door, and Josiane poked her head into the bathroom and whisked away his clothing and shoes. She was washing everything, naturally.

  Ruppol knew how close to disaster he had come with that baby. After rescuing the baby and getting fluids in his nose, mouth, and probably in his eyes, he had been absolutely terrified, more frightened than he had ever been in his life.

  He couldn’t not think about the married couple he’d examined in the hospital room, the woman curled up on the bed, the man frozen in the chaise lounge and staring at his wife, and the sight of the man’s hand reaching out of the flames in the burning grave. All he had done was to try to save a baby. The married couple had caught the virus trying to save their baby, too. Ruppol had spent days giving lectures all over Bumba Zone, telling the people that they must harden their hearts, they must not touch their loved ones or the dead, or they could catch the disease. That they must follow the Ancient Rule. And then he had failed to follow the Rule. And why? It was because his human emotions and his doctor’s instinct had swept away the Rule, and he had tried to save a child’s life.

  After Ruppol had stabilized the baby, he had placed it and its mother in a hammock, in a spot at the hospital that seemed free of the virus. The purpose of the hammock was to keep the mother’s pelvic bones pressed together while they healed from the Zárate cut. Afterward, he didn’t tell the team about his mistake. He kept a perfectly calm professional manner with the CDC doctors and the Belgian virologists, but terror crawled inside him. At the time, the international medical team had had absolutely no idea that Ruppol was in agony.

  A mother and her baby who were infected with the virus would both always die: This was known about the virus. He watched the mother and her child like a hawk. If the baby died or the mother’s illness got worse, it would
mean he was infected.

  He watched them for forty-eight hours. After that time, they were still alive and seemed to be doing fairly well. Ruppol’s crisis of nerves passed. He decided that she had had a very bad case of malaria. Malaria could produce some of the same symptoms as the X virus: It turns a person’s eyes bright red, it produces a high fever, with diarrhea and vomiting, and there can be blood in the urine and blood coming from the intestines. But you can catch malaria only from the bite of a mosquito, you can’t catch it from birth fluids, even if you swallow them and get them up your nose. Eventually the mother and her baby were discharged and went home.

  Now, as he soaked in the bath, Ruppol felt only a minor sense of satisfaction about the Bumba affair. The nameless agent was in retreat and was nearly gone. Case closed, pretty much. He and the international team hadn’t done much to stop the virus, but he’d saved a baby, anyway. At least he hadn’t killed himself, which would have been an embarrassment to the Belgian medical mission as well as to his reputation.

  The only thing that he and Raffier and Buassa had done was to give people information, in local languages, about how the virus was transmitted and how to protect themselves. They had involved the community. Once people grasped the nature of the virus, they did what was necessary. The virus had turned out to be a piddle. Now he could get back to doing epidemiology on bad pathogens, like sleeping sickness, which could wipe out whole villages and wasn’t under control.

  Ruppol began to smell smoke.

  He got dressed and went outdoors to the patio to have dinner with his family. That was when he noticed the remains of a fire smoldering in the fireplace by the kitchen. This seemed odd, as it was the usual sort of hot, muggy evening in Kinshasa. “What’s burning?” he asked Josiane.

  His clothes, she informed him. His shoes as well. Actually, she told him, she’d dumped the entire contents of his valise into the fire—she’d turned his valise upside down over the flames and shaken it out. His toothbrush, socks, razor, comb, pipe and tobacco, underwear, everything had gone into the fire, and then, for good measure, she had dropped the valise onto the fire as well.

  He thanked her for doing this. In his view, she had done exactly the right thing. Burn anything that’s been in contact with the virus. Follow the Ancient Rule. A simple rule practiced for possibly thousands of years in the Congo Basin. In the first outbreak of Ebola virus, the Ancient Rule had prevailed.

  * * *

  —

  Today, Jean-François Ruppol and Josiane Wissocq live in a small house made of stones in a small village in Belgium, where they enjoy the company of their grandchildren. Ruppol is not interested in publicity. Generally he refuses interviews. He says that he doesn’t think very often about the first outbreak of Ebola in 1976, though he does keep up with old friends from his days in Zaire. Some of them have died.

  I join the Ruppol family for lunch at their dining table. Josiane, a bright woman with a mischievous smile and a sharp sense of humor, has fixed a generous meal. The Ebola problem was a straightforward matter, Ruppol says. He shrugs when he talks about it. It was just a simple outbreak, a matter of giving people correct information about the virus. You involve the local communities in the fight. As we eat a dessert of clafoutis and discuss Ebola, Josiane relates her fear that the Americans would return Jean-François as a corpse inside some sort of unbelievable NASA device. She says she told him to drink all of the bottle of whisky. Imagine how difficult it must have been for Jean-François, she says, after he swallowed all that jus de mucus—mucus juice. “I dropped his valise on the fire, too,” she says, brushing her hands together in a gesture of good riddance. After lunch we go outdoors to the patio and sit under a wisteria arbor, where Dr. Ruppol lights a pipe and smiles.

  Ebola, he points out, was not like sleeping sickness, which killed a lot of people and was virtually impossible to control. Ruppol’s point is that after he and his two colleagues gave some speeches to the local people informing them of the virus’s mode of transmission—through contact with liquids of the body—the people took care of it themselves. They didn’t touch the dead and they buried bodies quickly. The Ancient Rule stopped the virus in a very short time. As for the question of who first discovered Ebola virus, Ruppol didn’t think the CDC or Patricia Webb deserved the primary credit. “Who first discovered Ebola?” he says, smiling and holding his pipe. “The people of Zaire discovered Ebola. They discovered it in their bodies.”

  * * *

  —

  As for Dr. Jean-Jacques Muyembé-Tamfun, he never broke with Ebola disease. He doesn’t understand why he didn’t die in the outbreak of 1976. Not the slightest idea why he is alive today. “I think I am lucky,” he says. He had multiple massive exposures to infected blood, including when he cut the piece of liver out of the young nurse and drenched his hand with blood that was saturated with Ebola particles. He had ridden for hours in a Land Rover next to Sister Myriam, pressed up against her, and he would never forget the feverish heat coming off her body or the way the rash moved down her arms. The fact that Muyembé is alive today is one of the many enigmas of Ebola virus. Muyembé’s survival is as much of a puzzle to his fellow Ebola experts as it is to himself. “I still don’t know how Muyembé and Ruppol survived,” Peter Piot recently said. Piot was a young member of the 1976 international Ebola epi team in Yambuku, and is now the director of the London School of Hygiene and Tropical Medicine. “I always think that the absence of bad luck is the most important thing in life,” Piot said.

  Today Muyembé is one of the world’s leading experts on Ebola virus. He is a major figure in medicine in the Democratic Republic of the Congo. He has trained approximately 70 percent of the doctors who currently practice medicine there. Ever since 1976, Muyembé has managed outbreak responses to Ebola whenever the virus emerged in his country. He has gone on expeditions to try to identify the virus’s natural host. He has also hunted and tracked monkeypox, a blistering virus that jumps out of jungle squirrels into primates, including humans. Monkeypox could someday change and invade dense primate colonies such as Tokyo, London, and Silicon Valley. In 2009, Muyembé and colleagues, investigating a strange, lethal disease that had broken out in a village called Mangala in Lower Congo, discovered a previously unseen rabies-like bat virus that they named Bas-Congo. When Bas-Congo gets into humans it causes a sort of blend of rabies and bleeding, and it is contagious in humans. Nobody has any idea if Bas-Congo rabies could someday blow up in the human species. Bas-Congo virus may remain a hideous curiosity, or it may go far in people. There are almost certainly other Bas-Congo-like rabies viruses circulating in bats, and someday another one of them may get into people. The only certain thing about emerging viruses is that they are deeply unpredictable. Muyembé has also devoted much of his career toward the battle with the emerging virus HIV, and he is one of the world’s leaders in the fight against AIDS in Africa. In 2014, Muyembé was awarded the Christophe Mérieux Prize in medicine for his contributions to research and outbreak response.

  PART FOUR

  CRISIS IN THE RED ZONE

  SITUATION REPORT

  JULY 4, 2014

  One day after the death of Nurse Lucy May

  In the years since 1976, when Ebola first appeared, our understanding of viruses and infectious diseases has deepened. Today, much more is known about viruses—about the structure of virus particles, how viruses get inside cells, what they do inside cells, how viruses jump host species, how they change over time. The classification of viruses has become more detailed and precise. Six species of Ebola have been discovered and given names. It’s possible that more Ebolas will be discovered; no one knows.

  Genomics, the science of the genetic code, has become extraordinarily powerful, and it is delivering deep insights into how organisms function, including the human organism. Genomics is also revealing new information about the history of life on the planet, and is uncovering secrets of human evolution and the h
istory of human populations. A highly accurate technique of reading genetic code called deep sequencing has proved to be extremely powerful. Deep sequencing can be used to collect and analyze the genetic code of all the organisms in a given sample—deep sequencing gives a panoramic view of all the life forms that exist in a place in the natural world. For example, a small amount of seawater can be deep sequenced: This reveals all of the genetic code in the water—DNA and RNA—from whatever creatures and viruses are in the water. Deep sequencing has revealed that viruses are everywhere.

  At the Broad Institute, Pardis Sabeti and her War Room colleagues were doing deep sequencing of the blood of Ebola patients in order to recover the exact letters of code of the kinds of Ebola that had been replicating in each patient’s cells. They were trying to get a panoramic view of the Ebola swarm in all its variations as it infected people in the Makona Triangle. Their purpose was to try to learn as much about the West African Ebola as they could, as quickly as possible, so that they could make recommendations to health authorities about control measures, and so that they could see whether the virus was changing significantly.