“What’s that?” I asked.
“The Zarate procedure? It’s a simple and rather crude but very effective way of enlarging the outlet to remove the baby. With a knife, you split the pubic symphysis.”
Sister Beata waving good-bye on the Ebola River. In 1976 she would die of Ebola while a priest, Father Lootens, wiped bloody tears from her face with his handkerchief and then unthinkingly wiped the tears from his own face, a mistake that sealed his doom.
Courtesy of William T. Close
“The what?”
“The front of the pelvis. The pelvic bones,” he said. It’s a hard, bony spot, and you can feel it, just above the pubic area, he said. “You split the bones there. You press a scalpel through cartilage. The bones go pop and the pelvis springs open, and you pull the baby out. The hospital had run out of anesthetics. So he did the Zarate procedure on the woman without giving her an anesthetic.”
“My God.”
“She was conscious. By the time he got the baby out, the baby had stopped breathing. The baby was in breathing arrest and drenched with the woman’s blood. He put the baby’s mouth to his mouth and gave the baby mouth-to-mouth resuscitation. The baby started to breathe. He pulled away, and his mouth and face were smeared with blood. There was a nurse standing by. When she saw his face she said, ‘Doctor, do you realize what you’ve done?’
“‘I do now,’ he said.”
5. Seeking the Ghost
WHEN THE WHO TEAM ARRIVED in Kikwit, they found Dr. Mpia Bwaka working alone in Pavilion Three with only two nurses—the third nurse had died of Ebola a few days earlier. Dr. Bwaka seemed to be all right. The WHO team had brought medical supplies, including jugs of bleach. They washed the ward with the bleach, rinsing the blood and feces off the floor. The team members put on double rubber gloves, waterproof gowns, masks, and goggles, and distributed the same equipment to Dr. Bwaka and his nursing staff. They wrapped the mattresses (which were blood-soaked) in plastic covers. Afterward, Ebola patients were placed directly on the plastic, without sheets. A Belgian team from Doctors Without Borders arrived a few days later, and put up white Tyvek sheets around Pavilion Three, as a sort of crude barrier to keep the virus inside the pavilion; the Belgian team also brought water for the hospital. Dr. Bwaka continued to work in the Ebola ward. It was so hot that the goggles fogged up, so the medical workers often didn’t wear them. One day, a nurse forgot himself momentarily and wiped his eyelid with his gloved fingertip, which was contaminated with Ebola blood. He died of Ebola.
But by the time the teams arrived in Kikwit, the outbreak was fading away. What really ended it was the fact that the virus had killed a third of the doctors in the city. Once the medical system collapsed, people didn’t go to the hospitals where the virus had spread. The outbreak burned itself out. Dr. Mpia Bwaka survived.
* * *
IN THE FOLLOWING MONTHS, a team of epidemiologists and zoologists led by Herwig Leirs, an ecologist at the Danish Pest Infestation Laboratory in Lyngby, Denmark, fanned out into the countryside around Kikwit and began trapping animals and birds and testing their blood. They were trying to find a species of animal that was either infected with Ebola or had antibodies to Ebola in its bloodstream, which would suggest that the animal was a natural carrier of the virus. They set out traplines and mist nets all through the forest of Mbwambala, and in other places in the countryside around the city. In the end, they collected slightly more than three thousand specimens. Most of them were mammals. About ten percent of the specimens were birds, and a few of them were reptiles and amphibians. Most of the mammals were rodents, and there were a number of bats. But they also collected wild African cats, as well as wild red pigs, pangolins, and elephant shrews. Not one of the specimens turned up positive for Ebola virus. Not one.
The Danish team didn’t look at any insects. Insect biodiversity in tropical Africa is enormous and unfathomed—many species of insects in Congo have never been identified or given names. A collecting team led by Paul Reiter of the CDC went around Kikwit and the countryside and collected thirty-five thousand arthopods—insects, ticks, sand flies, fleas, lice. They collected many bedbugs from around the city. For some reason, they didn’t catch any spiders or scorpions. They also didn’t report collecting any mites. (Mites are very small arthropods that are very difficult to see and collect.) Mites can live in hair follicles or on the skin of an animal or person, as well as in soil. The CDC arthropod team didn’t find any trace of Ebola in any of the thirty-five thousand specimens. No Ebola in a single bug.
It left the mystery unsolved. In what creature does Ebola make its everyday home? One interesting question about Ebola is this: Why aren’t humans infected more often with Ebola? Why are the outbreaks actually quite rare? If Ebola lives in some common animal or insect, then people should become infected more frequently. Possibly Ebola lives in primeval rain-forest canopies, in some creature that exists high above the ground in the remains of an ancient forest ecosystem. When a forest is disturbed—when trees are chopped down—people come in contact with the canopy and all that lives there. Perhaps the first man with Ebola in Kikwit, G.M., cut a tree down, then touched or ate a bat, bird, or insect that lived only in the tops of trees. Or perhaps he got Ebola from something that had lived underground, something he found in the small hole he dug that day in Mbwambala. He was dead, and many members of his family—who might otherwise have been able to recall details of his activities during the days when he became infected—were dead, too. Ebola kills the witnesses to its appearance. There were hints that some type of bat might be the natural host of Ebola. In laboratory tests, Ebola virus has been able to infect certain kinds of bats without making them sick. The bat’s immune system is resistant to Ebola, which suggests bats may be carriers of the virus. Even so, no wild bats have ever been found with Ebola in them.
Bats have very unusual wingless parasitic flies that live on them, sucking their blood. These bloodsucking bat flies, called strebelid flies, crawl from bat to bat while the bats are hanging in roosts. The flies might transmit Ebola among the bats. Does Ebola live in wingless flies crawling on bats? Nobody knows.
This is a story with no end. Recently, I called Dr. William Close, to see how he was doing. He lives in Big Piney, Wyoming.
“That Belgian doctor,” I said. “The one who got the Ebola-infected blood all over his face? How long did he survive?”
Close began chuckling. “More than thirty years, so far. I just talked with him yesterday. Jean-François Ruppol. He’s a great friend of mine. He lives in Belgium now.”
I could hardly believe it. How could anyone survive an Ebola exposure like that?
Not long afterward, I received a series of pleasant e-mails from Dr. Jean-François Ruppol. He had written down, in French, some of his recollections of the first Ebola outbreak, in Yambuku, near the Ebola River, Congo, in 1976. Ruppol went to Yambuku three times during the outbreak, seeking to understand the virus and get it under control. (At the time, Ebola virus did not yet have a name.) Here, in Ruppol’s words, is what happened:
Ma première nuit à Yambuku fut calme…. My first night in Yambuku was calm, but around five o’clock in the morning, a nursing sister woke me, banging on the door of the room I was occupying. A woman had just been brought in who had been in labor for a full day, and her situation didn’t look good. I have to admit that I was a little nervous. For one thing, I didn’t want to go into the hospital or the maternity ward, where there had been numerous sick patients and where the virus might still be present in patches of blood and soiled sponges that were scattered all about. For another thing, practically all of the male and female nurses had died, and the survivors had fled. Was the woman they had just brought in contaminated?
At this point, I asked a nun if they could put a kitchen table on the building’s porch. We put the pregnant woman on the table, after we had donned protective gear (gown, cap, mask, gloves, etc.). I wanted to take all the necessary precautions, the same ones I had ordered others to use
during this epidemic.
In the course of my examination, I came to the following conclusions:
• The woman was at the end of her rope.
• The fetus was presenting in a dangerous way. If I remember correctly, the fetus was stuck sideways, making birth impossible.
• The fetus was in extremis.
We had to act quickly. But a caesarean was impossible because of the dangers in the operating room, the blood and foul sponges, and because of the absence of qualified personnel. Therefore I decided to utilize a technique that I had occasionally practiced in Kimpangu, the symphysisiotomy [the Zarate procedure]. It consisted of cutting the cartilage at the pubic symphysis, and then spreading the legs to open the pelvis and favor the passage of the fetus.
Getting the help of two people to hold the mother’s knees and legs, I performed the Zarate procedure under a local anesthetic, and I reached in and turned the fetus around inside her, in order to deliver it bottom-first.
Illuminated by flashlights and an electric light from a generator, the maneuver went well, but once the baby was delivered and the umbilical cord cut, the baby would not breathe despite various attempts to wake it up. Then, pushed by habit (or instinct, perhaps?), I took down my mask and practiced gentle mouth-to-mouth resuscitation. At that very moment I got a terrible shock: I realized that if the woman was infected with the virus, then I had just condemned myself to death. This was because we knew the virus was transmitted in all the secretions and fluids of the body. Even so, the child was revived and the mother seemed to be doing all right. It’s hardly necessary to add that I spent the next forty-eight hours keeping a very close watch on the health of the mother and baby. Oof! They weren’t contaminated, and I was alive. This was the only time in my medical career when I was not just afraid, but felt and lived real terror….
Ruppol had lost his sense of self-protection during the emergency, but had gotten lucky. The mother hadn’t had Ebola.
Close thought it was just typical of the way doctors can forget themselves when a patient is in trouble. It didn’t give him any confidence, though, that the doctors had the situation with emerging viruses and microbes under control. “In the battle between the doctors and the bugs,” he remarked, “in the long run, I’d put my money on the bugs.”
The Human Kabbalah
“CRAIG VENTER IS AN ASS. He’s an idiot. He is a thorn in people’s sides and an egomaniac,” a senior scientist in the Human Genome Project said to me one day. The Human Genome Project was an ongoing nonprofit international research consortium that had been working to decipher the complete sequence of nucleotides, or letters, in human DNA. The human genome is the total amount of DNA that is spooled into a set of twenty-three chromosomes in the nucleus of every typical human cell. (There are two sets of chromosomes, for a total of forty-six chromosomes in each human cell.) This entire package of DNA in every cell is sometimes referred to as the book of human life. Most scientists agreed that deciphering it would be one of the great achievements of our time. The stakes, in money and glory, to say nothing of the future of medicine, were huge and incalculable.
In the United States, most of the money to pay for the Human Genome Project had been coming from the National Institutes of Health, the NIH. The project was often referred to, in a kind of shorthand, as the “public project,” to distinguish it from for-profit enterprises like the Celera Genomics Group, of which Craig Venter was the president and chief scientific officer. “In my perception,” said the scientist who was giving me the dour view of Venter, “Craig has a personal vendetta against the National Institutes of Health. I look at Craig as being an extremely shallow person who is only interested in Craig Venter and in making money. Only God knows what those people at Celera are doing.”
What Venter and his colleagues were doing was preparing to announce that they had placed in the proper order something like 95 percent of the readable letters in the human genetic code. They were referring to this milestone as the first assembly. They had already started selling information about the human genome to subscribers. The Human Genome Project, largely in response to Craig Venter and the corporate effort to read the human book of life, was also on the verge of announcing a milestone. Its scientists were calling their milestone a “working draft” of the genome. They were claiming it was more than 90 percent complete, and they were making the information available to anyone, free of charge, on a database called GenBank. Both images of the human genome—Celera’s and the public project’s—were becoming clearer and clearer. The book of life and death was opening, and we held it in our hands.
* * *
A HUMAN DNA MOLECULE is about a meter long. It is about a twenty-millionth of a meter wide—the width of twenty hydrogen atoms. It is shaped like a twisted ladder. Each rung of the ladder is made of one of four nucleotides—adenine, thymine, cytosine, and guanine. The DNA code is expressed in combinations of the letters A, T, C, and G, the first letters of the names of the nucleotides. The human genome contains at least 3.2 billion letters of genetic code. This is about the number of letters in three thousand copies of Moby-Dick.
Perhaps three percent of the human code consists of genes. Genes hold the recipes for making proteins. Human genes are stretches of between a thousand and fifteen hundred letters of code, often broken into pieces and separated by long passages of DNA that don’t code for proteins. It is believed that there are about twenty-five thousand genes in the human genome. Much of the rest of the genome consists of blocks of seemingly meaningless letters, gobbledygook. These sections are referred to as junk DNA, although it may be that we just don’t understand the function of the apparent junk.
The conventional route for announcing scientific breakthroughs is publication in a scientific journal. Both Celera and the Human Genome Project were planning to publish annotated versions of the human genome as soon as possible. Although the two sides looked like armies maneuvering for advantage, the leaders of the Human Genome Project had always denied that they were involved in some kind of competition with Craig Venter.
“They’re trying to say it’s not a race, right?” Venter said to me, in a shrugging sort of way. “But if two sailboats are sailing near each other, then by definition it’s a race. If one boat wins, then the winner says, ‘We smoked them,’ and the loser says, ‘Eh, we weren’t racing—we were just cruising.’”
I first met Craig Venter on a windy day in the summer of 1999, at Celera’s headquarters in Rockville, Maryland, a half-hour drive northwest of Washington, D.C. The company’s offices and laboratories occupied a pair of five-story white buildings with mirrored windows, surrounded by beautiful groves of red oaks and yellow poplar trees. One of the buildings contained rooms packed with row after row of DNA-sequencing machines of a type known as the ABI Prism. The other building held what was said to be the most powerful civilian computer array in the world. The Celera supercomputer complex was of considerable interest to Gregory and David Chudnovsky, the mathematicians who had used a homemade supercomputer to calculate the number pi, and who ended up meeting with Craig Venter and his staff, talking with them about the design of supercomputers and software used in sequencing the human genome. Venter’s supercomputer complex was surpassed only, perhaps, by that of the Los Alamos National Laboratory, which is used for simulating nuclear bomb explosions.
The computer building at Celera also contained the Command Center. This was a room stuffed with control consoles and computer screens. The Command Center was manned all the time. It monitored the flow of DNA inside Celera. The DNA was flowing through the machines twenty-four hours a day, seven days a week.
That hot summer day, Craig Venter moved restlessly around his office. There had been a spate of newspaper stories about the race to decode the complete genome, and about the pressure Celera was putting on its competitors. “We’re scaring the crap out of everybody, including ourselves,” he said to me.
Venter was fifty-three at the time. He had an active, cherubic face on which a s
mile often flickered. He was bald, with a fuzz of short hair at the temples, and his head was usually sunburned. He had bright blue eyes and a soft voice. That day, he was wearing khaki slacks and a blue shirt, New Balance running shoes, a preppy tie with small turtles on it, and a Rolex watch. Venter’s office looked out into stands of trees; leaves were spinning on branches outside the windows, flashing their white undersides and promising thunderstorms. Beyond the trees, a chronic traffic jam was occurring on the Rockville Pike. Celera was in an area along a stretch of Interstate 270 known as the biotechnology corridor, which was dense with companies specializing in the life sciences, and billions of dollars in venture capital were embedded in bioenterprises all around Celera.
Celera Genomics was a part of the PE Corporation, which had been called Perkin-Elmer before the company’s chief executive, Tony L. White, split the business into two parts: PE Biosystems, now called Applera, which made the DNA sequencing machine called the Prism, and Celera. Venter owned five percent of Celera’s stock. It had been trading, often violently, on the New York Stock Exchange. The stock had been tossed by waves of panic selling and panic buying. That particular summer day, the stock market was valuing Celera at around three billion dollars. Craig Venter’s own net worth had been slopping around by five or ten million dollars a day in either direction, like water going back and forth in a bathtub.
“Our fundamental business model is like Bloomberg’s,” Venter said. “We’re selling information about the vast universe of molecular medicine.” Venter hoped, for example, that one day Celera would help analyze the genomes of millions of people as a regular part of its business. This would be done over the Internet, he felt—and, having decoded individual patients’ DNA, the company would then help design or select drugs tailored to patients’ particular needs. In recent times, genomics has been moving so fast that it’s possible to think that pretty soon you will be able to walk into a doctor’s office and have your own genome read and interpreted. It could be stored in a smart card. (You would want to keep the card in your wallet, in case you landed in an emergency room. But you wouldn’t want to lose it, because if thieves got your DNA sequence, they might really be able to clone you.) Your doctor would read the smart card, and it would show your total biological-software code. Your doctor would be able to see the bugs in your code. The bugs are genes that make you vulnerable to certain diseases; everyone has bugs in their code. If you became sick, doctors could watch the activity of your genes, using so-called gene chips, which are small pieces of glass containing detectors for every gene. Doctors could track how your body responded to treatment. All your genes could be observed, operating in an immense symphony.
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