The Hot Zone (5 page)

The nurse gave it to him in the muscle of his
arm. The pain of the injection was very, very bad. He had never felt such pain from a shot; it was abnormal and memorable. He wondered why a simple shot would give him this kind of pain. Then he developed abdominal pain, and that made him think that he might have typhoid fever, so he gave himself a course of antibiotic pills, but that had no effect on his illness. Meanwhile, his patients needed him, and he continued to work at the hospital. The pain in his stomach and in his muscles grew unbearable, and he developed jaundice.

Unable to diagnose himself, in severe pain, and unable to continue with his work, he presented himself to Dr. Antonia Bagshawe, a physician at Nairobi Hospital. She examined him, observed his fever, his red eyes, his jaundice, his abdominal pain, and came up with nothing definite, but wondered if he had gallstones or a liver abscess. A gall-bladder attack or a liver abscess could cause fever and jaundice and abdominal pain—the red eyes she could not explain—and she ordered an ultrasound examination of his liver. She studied the images of his liver and saw that it was enlarged, but, other than that, she could see nothing unusual. By this time, he was very sick, and they put him in a private room with nurses attending him around the clock. His face set itself into an expressionless mask.

This possible gallstone attack could be fatal. Dr. Bagshawe recommended that Dr. Musoke have exploratory surgery. He was opened up in the main operating theater at Nairobi Hospital by
a team of surgeons headed by Dr. Imre Lofler. They made an incision over his liver and pulled back the abdominal muscles. What they found inside Musoke was eerie and disturbing, and they could not explain it. His liver was swollen and red and did not look healthy, but they could not find any sign of gallstones. Meanwhile, he would not stop bleeding. Any surgical procedure will cut through blood vessels, and the cut vessels will ooze for a while and then clot up, or if the oozing continues, the surgeon will put dabs of gel foam on them to stop the bleeding. Musoke’s blood vessels would not stop oozing—his blood would not clot. It was as if he had become a hemophiliac. They dabbed gel foam all over his liver, and the blood came through the foam. He leaked blood like a sponge. They had to suction off a lot of blood from the incision, but as they pumped it out, the incision filled up again. It was like digging a hole below the water table: it fills up as fast as you pump it out. One of the surgeons would later tell people that the team had been “up to the elbows in blood.” They cut a wedge out of his liver—a liver biopsy—and dropped the wedge into a bottle of pickling fluid and closed up Musoke as quickly as they could.

He deteriorated rapidly after the surgery, and his kidneys began to fail. He appeared to be dying. At that time, Antonia Bagshawe, his physician, had to travel abroad, and he came under the care of a doctor named David Silverstein. The prospect of kidney failure and dialysis for Dr. Musoke created
a climate of emergency at the hospital—he was well liked by his colleagues, and they didn’t want to lose him. Silverstein began to suspect that Musoke was suffering from an unusual virus. He collected some blood from his patient and drew off the serum, which is a clear, golden-colored liquid that remains when the red cells are removed from the blood. He sent some tubes of frozen serum to laboratories for testing—to the National Institute of Virology in Sandringham, South Africa, and to the Centers for Disease Control in Atlanta, Georgia, U.S.A. Then he waited for results.

David Silverstein lives in Nairobi, but he owns a house near Washington, D.C. One day in the summer recently, when he was visiting the United States to tend to some business, I met him in a coffee shop in a shopping mall not far from his home. We sat at a small table, and he told me about the Monet and Musoke cases. Silverstein is a slender, short man in his late forties, with a mustache and glasses, and he has an alert, quick gaze. Although he is an American, his voice carries a hint of a Swahili accent. On the day that I met him, he was dressed in a denim jacket and blue jeans, and he was nicely tanned, looking fit and relaxed. He is a pilot, and he flies his own plane. He has the largest private medical practice in East Africa, and it has made him a famous figure in Nairobi. He is the personal physician of Daniel arap Moi, the president of Kenya, and he travels with President Moi when Moi goes abroad. He treats all the important people in East Africa: the corrupt politicians, the actors and actresses who
get sick on safari, the decayed English-African nobility. He traveled at the side of Diana, Lady Delamere, as her personal physician when she was growing old, to monitor her blood pressure and heartbeat (she wanted to carry on with her beloved sport of deep-sea fishing off the Kenya coast, although she had a heart condition), and he was also Beryl Markham’s doctor. Markham, the author of
West with the Night
, a memoir of her years as an aviator in East Africa, used to hang out at the Nairobi Aero Club, where she had a reputation for being a slam-bang, two-fisted drinker. (“She was a well-pickled old lady by the time I came to know her.”) His patient Dr. Musoke has himself become a celebrity, in the annals of disease. “I was treating Dr. Musoke with supportive care,” Silverstein said to me. “That was all I could do. I tried to give him nutrition, and I tried to lower his fevers when they were high. I was basically taking care of somebody without a game plan.”

One night, at two o’clock in the morning, Silverstein’s telephone rang at his home in Nairobi. It was an American researcher stationed in Kenya calling him to report that the South Africans had found something very queer in Musoke’s blood: “He’s positive for Marburg virus. This is really serious. We don’t know much about Marburg.”

Silverstein had never heard of Marburg virus. “After the phone call, I could not get back to sleep,” he said to me. “I had kind of a waking dream about it, wondering what Marburg was.”
He lay in bed, thinking about the sufferings of his friend and colleague Dr. Musoke, fearful of what sort of organism had gotten loose among the medical staff at the hospital. He kept hearing the voice saying, “We don’t know much about Marburg.” Unable to sleep, he finally got dressed and drove to the hospital, arriving at his office before dawn. He found a medical textbook and looked up Marburg virus.

The entry was brief. Marburg is an African organism, but it has a German name. Viruses are named for the place where they are first discovered. Marburg is an old city in central Germany, surrounded by forests and meadows, where factories nestle in green valleys. The virus erupted there in 1967, in a factory called the Behring Works, which produced vaccines using kidney cells from African green monkeys. The Behring Works regularly imported monkeys from Uganda. The virus came to Germany hidden somewhere in a series of air shipments of monkeys totaling five or six hundred animals. As few as two or three of the animals were incubating the virus. They were probably not even visibly sick. At any rate, shortly after they arrived at the Behring Works, the virus began to spread among them, and a few of them crashed and bled out. Soon afterward, the Marburg agent jumped species and suddenly emerged in the human population of the city. This is an example of virus amplification.

The first person known to be infected with the Marburg agent was a man called Klaus F., an employee
at the Behring Works vaccine factory who fed the monkeys and washed their cages. He broke with the virus on August 8, 1967, and died two weeks later. So little is known about the Marburg agent that only one book has been published about it, a collection of papers presented at a symposium on the virus, held at the University of Marburg in 1970. In the book, we learn that

And so on. The victims developed headaches at about day seven after their exposure and went downhill from there, with raging fevers, clotting, spurts of blood, and terminal shock. For a few days in Marburg, doctors in the city thought the world was coming to an end. Thirty-one people eventually caught the virus; seven died in pools of blood. The kill rate of Marburg turned out to be about one in four, which makes Marburg an extremely lethal agent: even in the best modern hospitals, where the patients are hooked up to life-support machines, Marburg kills a quarter of the patients who are infected with it. By contrast, yellow fever, which is considered a highly lethal virus,
kills only about one in twenty patients once they reach a hospital.

Marburg is one of a family of viruses known as the filoviruses. Marburg was the first filovirus to be discovered. The word
filovirus
is Latin and means “thread virus.” The filoviruses look alike, as if they are sisters, and they resemble no other virus on earth. While most viruses are ball-shaped particles that look like peppercorns, the thread viruses have been compared to strands of tangled rope, to hair, to worms, to snakes. When they appear in a great flooding mess, as they so often do when they have destroyed a victim, they look like a tub of spaghetti that has been dumped on the floor. Marburg particles sometimes roll up into loops. The loops resemble Cheerios. Marburg is the only ring-shaped virus known.

In Germany, the effects of Marburg virus on the brain were particularly frightening, and resembled the effects of rabies: the virus somehow damaged the central nervous system and could destroy the brain, as does rabies. The Marburg particles also looked rather like rabies particles. The rabies-virus particle is shaped like a bullet. If you stretch out a bullet, it begins to look like a length of rope, and if you coil the rope into a loop, it becomes a ring, like Marburg. Thinking that Marburg might be related to rabies, they called it stretched rabies. Later it became clear that Marburg belongs to its own family.

Not long after Charles Monet died, it was established that the family of filoviruses comprised
Marburg along with two types of a virus called Ebola. The Ebolas were named Ebola Zaire and Ebola Sudan. Marburg was the mildest of the three filovirus sisters. The worst of them was Ebola Zaire. The kill rate in humans infected with Ebola Zaire is nine out of ten. Ninety percent of the people who come down with Ebola Zaire die of it. Ebola Zaire is a slate wiper in humans.

Marburg virus (the gentle sister) affects humans somewhat like nuclear radiation, damaging virtually all of the tissues in their bodies. It attacks with particular ferocity the internal organs, connective tissue, intestines, and skin. In Germany, all the survivors lost their hair—they went bald or partly bald. Their hair died at the roots and fell out in clumps, as if they had received radiation burns. Hemorrhage occurred from all orifices of the body. I have seen a photograph of one of the men who died of Marburg, taken in the hours before his death. He is lying in bed without any clothing on his upper body. His face is expressionless. His chest, arms, and face are speckled with blotches and bruises, and droplets of blood stand on his nipples.

During the survivors’ recovery period, the skin peeled off their faces, hands, feet, and genitals. Some of the men suffered from blown up, inflamed, semirotten testicles. One of the worst cases of this testicular infection appeared in a morgue attendant who had handled Marburg-infected bodies and who himself came down with Marburg, having caught it from the cadavers. The
virus also lingered in the fluid inside the eyeballs of some victims for many months. No one knows why Marburg has a special affinity for the testicles and the eyes. One man infected his wife with Marburg through sexual intercourse.

Doctors noticed that the Marburg agent had a strange effect on the brain. “Most of the patients showed a sullen, slightly aggressive, or negativistic behavior,” according to the book. “Two patients [had] a feeling as if they were lying on crumbs.” One patient became psychotic, apparently as a result of brain damage. The patient called Hans O.-V. showed no signs of mental derangement, and his fever cooled, and he seemed to be stabilizing, but then suddenly, without warning, he had an acute fall in blood pressure—he was crashing—and he died. They performed an autopsy on him, and when they opened his skull, they found a massive, fatal hemorrhage at the center of the brain. He had “bled out” into his brain.

International health authorities were urgently concerned to find the exact source of the monkeys, in order to pin down where in nature the Marburg virus lived. It seemed pretty clear that the Marburg virus did not naturally circulate in monkeys, because it killed them so fast it could not successfully establish itself in them as a useful host. Therefore, Marburg lived in some other kind of host—an insect? a rat? a spider? a reptile? Where, exactly, had the monkeys been trapped? That place would be the hiding place of the virus. Soon after the outbreak in Germany, a team of
investigators under the auspices of the World Health Organization flew to Uganda to try to find out where those monkeys had come from. It turned out they had been trapped at locations all over central Uganda. The team couldn’t discover the exact source of the virus.

There the mystery lingered for many years. Then, in 1982, an English veterinarian came forward with new eyewitness information about the Marburg monkeys. I will call this man Mr. Jones (today, he prefers to remain anonymous). During the summer of 1967, when the virus erupted in Germany, Mr. Jones was working at a temporary job inspecting monkeys at the export facility in Entebbe from which the sick Marburg monkeys had been shipped, while the regular veterinary inspector was on leave. This monkey house, which was run by a rich monkey trader (“a sort of lovable rogue,” according to Mr. Jones) was exporting about thirteen thousand monkeys a year to Europe. This was a very large number of monkeys, and it generated big money. The infected shipment was loaded onto an overnight flight to London, and from there it was flown to Germany—where the virus broke out of the monkeys and “attempted” to establish itself in the human population.