The Hot Zone

THE HOT ZONE.

by Richard Preston.

This book describes events between 1967 and 1993. The incubation period of the viruses in this book is less than twenty-four days. No one who suffered from any of the viruses or who was in contact with anyone suffering from them can catch or spread the viruses outside of the incubation period. None of the living people referred to in this book suffer from a contagious disease. The viruses cannot survive independently for more than ten days unless the viruses are preserved and frozen with special procedures and laboratory equipment. Thus none of the locations in Reston or the Washington, D.C. area described in this book is infective or dangerous.

The second angel poured his bowl into the sea, and it became like the blood of a dead man. -APOCALYPSE

PART ONE

THE SHADOW OF MOUNT ELGON.

SOMETHING IN THE FOREST.

1980 NEW YEAR"S DAY.

CHARLES MONET was a loner. He was a Frenchman who lived by himself in a little wooden bungalow on the private lands of Nzoia Sugar Factory, a plantation in western Kenya what spread along the Nzoia River within sight of Mount Elgon, a huge, solitary extinct volcano that rises to a height of fourteen thousand feet near the edge of the Rift Valley. Monet"s history is a little obscure. As with so many expatriates who end up in Africa, it is not clear what brought him there. Perhaps he had been in some kind of trouble in France, or perhaps he had been drawn to Kenya by the beauty of the country. He was an amateur naturalist, fond of birds and animals but not of humanity in general. He was fifty-six years old, of medium height and medium build, with smooth, straight brown hair, a good-looking man. It seems that his only close friends were women who lived in towns around the mountain, yet even they could not recall much about him for the doctors who investigated his death. His job was to take care of the sugar factory"s water-pumping machinery, which drew water from the Nzoia River and delivered it to many miles of sugar-cane fields. They say that he spent most of his day inside the pump house by the river, as if it pleased him to watch and listen to machines doing their work. So often in a case like this, it"s hard to pin down the details. The doctors remember the clinical signs, because no one who has seen the effects of a Biosafety Level 4 hot agent on a human being can ever forget them, but the effects pile up, one after the other, until they obliterate the person beneath them. The case of Charles Monet emerges in a cold geometry of clinical fact mixed with flashes of horror so brilliant and disturbing that we draw back and blink, as if we are staring into a discolored alien sun. Monet came into the country in the summer of 1979, around the time that human immunodeficiency virus, or HIV, which causes AIDS, made a final breakout from the rain forest of central Africa and began its long burn through the human race. AIDS had already fallen like a shadow over the population, although no one yet knew it existed. It had been spreading quietly along the Kinshasa Highway, a transcontinental road that wanders across Africa from east to west and pa.s.ses along the sh.o.r.es of Lake Victoria within sight of Mount Elgon. HIV is a highly lethal but not very infective Biosafety Level 2 agent. It does not travel easily from person to person, and it does not travel through the air. You don"t need to wear a biological suit while handling blood infected with HIV. Monet worked hard in the pump house during the week, and on his weekends and holidays he would visit forested areas near the sugar factory. He would bring food with him, and he would scatter it around and watch while birds and animals ate it. He could sit in perfect stillness while he observed an animal. People who knew him recalled that he was affectionate with wild monkeys, that he had a special way with them. They said that he would sit holding a piece of food while a monkey approached him, and the animal would eat from his hand. On the evenings, he kept to himself in his bungalow. He had a housekeeper, a woman named Johnnie, who cleaned up and prepared his meals. He was teaching himself how to identify African birds. A colony of weaverbirds lived in a tree near his house, and he spent time watching them build and maintain their baglike nests. They say that one day near Christmas he carried a sick bird into his house, where it died, perhaps in his hands. The bird may have been a weaverbird--no one knows--and it may have died of a Level 4 virus--no one knows. He also had a friendship with a crow. It was a pied crow, a black-and-white bird that people in Africa sometimes make into a pet. This crow was a friendly, intelligent bird that liked to peek on the roof of Monet"s bungalow and watch his comings and goings. When the crow was hungry, it would land on the veranda and walk indoors, and Monet would feed it sc.r.a.ps of food from his table. He walked to work every morning through the cane fields, a journey of two miles. That Christmas season, the workers had been burning the fields, and so the fields were scorched and black. To the north across the charred landscape, twenty-five miles away, he could see Mount Elgon. The mountain displayed a constantly changing face of weather and shadow, rain and sun, a spectacle of African light. At dawn, Mount Elgon appeared as a slumped pile of gray ridges receding into haze, culminating in a summit with two peaks, which are opposed lips of the eroded cone. As the sun came up, the mountain turned silvery green, the color of the Mount Elgon rain forest, and as the day progressed clouds appeared and hid the mountain from view. Late in the afternoon, near sunset, the clouds thickened and boiled up into an anvil thunderhead that flickered with silent lightning. The bottom of the cloud was the color of charcoal, and the top of the cloud feathered out against the upper air and glowed a dull orange, illuminated by the setting sun, and above the cloud the sky was deep blue and gleamed with a few tropical stars. He had a number of women friends who lived in the town of Eldoret, to the southeast of the mountain, where the people are poor and live in shacks made of boards and metal. He gave money to his women friends, and they, in return, were happy to love him. When his Christmas vacation arrived, he formed a plan to go camping on Mount Elgon, and he invited one of the women from Eldoret to accompany him. No one seems to remember her name. Monet and his friend drove in a Land Rover up the long, straight red-dirt road that leads to Endebess Bluff, a prominent cliff on the eastern side the volcano. The road was volcanic dust, as red as dried blood. They climbed onto the lower skirts of the volcano and went through cornfields and coffee plantations, which gave way to grazing land, and the road pa.s.sed old, half-ruined English colonial farms hidden behind lines of blue-gum trees. The air grew cool as they went higher, and crested eagles flapped out of cedar trees. Not many tourists visit Mount Elgon, so Monet and his friend were probably the only vehicle on the road, although there would have been crowds of people walking on foot, villagers who cultivate small farms on the lower slopes of the mountain. They approached the frayed outer edge of the Mount Elgon rain forest, pa.s.sing by fingers and islands of trees, and they pa.s.sed the Mount Elgon Lodge, an English inn built in the earlier part of century, now falling into disrepair, its walls cracked and its paint peeling off in the sun and rain. Mount Elgon straddles the border between Uganda and Kenya and is not far from Sudan. The mountain is a biological island of rain forest in the center of Africa, an isolated world rising above dry plains, fifty miles across, blanketed with trees, bamboo, and alpine moor. It is a k.n.o.b in the backbone of central Africa. The volcano grew up seven to ten million years ago, producing fierce eruptions and explosions of ash, which repeatedly wiped out the forests that grew on its slopes, until it attained a tremendous height. Before Mount Elgon was eroded down, it may have been the highest mountain in Africa, higher than Kilmanjaro is today. It is still the widest. When the sun rises, it throws the shadow of Mount Elgon westward and deep into Uganda, and when the sun sets, the shadow reaches eastward across Kenya. Within the shadow of Mount Elgon lie villages and cities inhabited by various tribal groups, including the Elgon Masai, a pastoral people who came from the north and settled around the mountain some centuries ago, and who raise cattle. The lower slopes of the mountain are washed with gentle rains, and the air remains cool and fresh all year, and the volcanic soil produces rich crops of corn. The villages form a ring of human settlement around the volcano, and the ring is steadily closing around the forest on its slopes, a noose that is tangling the wild habitat of the mountain. The forest is being cleared away, the trees are being cut down for firewood or to make room for grazing land, and the elephant are vanishing. A small part of Mount Elgon is a national park. Monet and his friend stopped at the park gate to pay their entrance fees. A monkey or perhaps a baboon--no one seems to remember--used to hang out around the gate, looking for handouts, and Monet enticed the animal to sit on his shoulder by offering it a banana. His friend laughed, but they stayed perfectly still while the animal ate. They drove a short way up the mountain and pitched their tent in a clearing of moist green gra.s.s that sloped down to a stream. The stream gurgled out of the rain forest, and it was a strange color, milky with volcanic dust. The gra.s.s was kept short by Cape buffalo grazing it, and was spotted with their dung. The Elgon forest towered around their campsite, a web of gnarled African olive trees hung with moss and creepers and dotted with a black olive that is poisonous to humans. They heard a scuffle of monkeys feeding in the trees, a hum of insects, an occasional low huh-huh call of a monkey. They were colobus monkeys, and sometimes one would come down from a tree and scuttle across the meadow near the tent, watching them with alert, intelligent eyes. Flocks of olive pigeons burst from the trees on swift downward slants, flying at terrific speed, which is their strategy to escape from harrier hawks that can dive on them and rip them apart on the wing. There were camphor trees and teaks and African cedars and red stinkwood trees, and here and there a dark green cloud of leaves mushroomed above the forest canopy. These were the crowns of podocarpus trees, or podos, the largest trees in Africa, nearly as large as California sequoias. Thousands of elephants lived on the mountain then, and they could be heard moving through forest, making cracking sounds as they peeled bark and broke limbs from trees. In the afternoon, it would have rained, as it usually does on Mount Elgon, and so Monet and his friend would have stayed in their tent, and perhaps they made love while a thunderstorm hammered the canvas. It grew dark; the rain tapered off. They built a fire and cooked a meal. It was New Year"s Eve. Perhaps they celebrated, drinking champagne. The clouds would have cleared off in a few hours, as they usually do, and the volcano would have emerged as a black shadow under the Milky Way. Perhaps Monet stood on the gra.s.s at the stroke of midnight and looked at the stars--neck bent backward, unsteady on his feet from the champagne. On New Year"s morning, sometime after breakfast--a cold morning, air temperature in the forties, the gra.s.s wet and cold--they drove up the mountain along a muddy track and parked in a small valley below Kitum Cave. They bushwhacked up the valley, following elephant trails that meandered besides a little stream that ran through stands of olive trees and gra.s.sy meadows. They kept an eye out for Cape buffalo, a dangerous animal to encounter in the forest. The cave opened at the head of the valley, and the stream cascaded over its mouth. The elephant trails joined at the entrance and headed inside. Monet and his friend spent the whole of New Year"s Day there. It probably rained, and so they would have sat in the entrance for hours while the little stream poured down in a veil. Looking across the valley, they watched for elephants, and they saw rock hyraxes--furry animals the size of groundhogs--running up and down the boulders near the mouth of the cave. Herds of elephants go inside Kitum Cave at night to obtain minerals and salts. On the plains, it is easy for elephants to find salt in hardpans and dry water holes, but in the rain forest salt is precious thing. The cave is large enough to hold as many as seventy elephant at a time. They spend the night inside the cave, dozing on their feet or mining the rock with their tusks. They pry and gouge rocks off the walls, and chew them to fragments between their teeth, and swallow the broken bits of rock. Elephant dung around the cave is full of crumbled rock. Monet and his friend had a flashlight, and they walked back into the cave to see where it went. The mouth of the cave is huge--fifty-five yards wide--and it opens out even wider beyond the entrance. They crossed a platform covered with powdery dry elephant dung, their feet kicking up puffs of dust as they advanced. The light grew dim, and the floor of the cave rose upward in a series of shelves coated with green slime. The slime was bat guano, digested vegetable matter that had been excreted by a colony of fruit bats on the ceiling. Bats whirred out of holes and flicked through their flashlight beams, dodging around their heads, making high-pitched cries. Their flashlights disturbed the bats, and more bats woke up. Hundreds of bat eyes, like red jewels, looked down on them from the ceiling of the cave. Waves of bat sound rippled across the ceiling and echoed back and forth, a dry, squeaky sound, like many small doors being opened on dry hinges. Then they saw the most wonderful thing about Kitum Cave. The cave is petrified rain forest. Mineralized logs stuck out of the walls and ceiling. They were trunks of rain-forest trees turned to stone--teaks, podo trees, evergreens. An eruption of Mount Elgon about seven million years ago had buried the rain forest in ash, and the logs had been tranformed into opal and chert. The logs were surrounded by crystals, white needles of minerals that had grown out of the rock. The crystals were as sharp as hypodermic syringes, and they glittered in the beams of the flashlights. Monet and his friend wandered through the cave, shining their lights on the petrified rain forest. Did he run his hands over the stone trees and p.r.i.c.k his finger on a crystal? They found petrified bones of ancient hippos and ancestors of elephants. There were spiders hanging in webs among the logs. The spiders were eating moths and insects. They came to a gentle rise, where the main chamber widened to more than a hundred yards across--wider than the length of a football field. They found a crevice and shined their lights down to the bottom. There was something strange down there--a ma.s.s of gray and brownish material. It was the mummified corpses of baby elephants. When elephants walk through the cave at night, they navigate by their sense of touch, probing the floor ahead of them with the tips of their trunks. The babies sometimes fall into the crevice. Monet and his friend continued deeper into the cave, descending a slope, until they came to a pillar that seemed to support the roof. The pillar was scored with hatch marks and grooves, the marks of elephant tusks. If the elephants continued to dig away at the base of the pillar, it might eventually collapse, bringing down the roof of Kitum Cave with it. At the back of the cave, they found another pillar. This one was broken. Over it hung a velvety ma.s.s of bats, which had fouled the pillar with black guano--a different kind of guano from the green slime near the mouth of the cave. These bats were insect eaters, and the guano was an ooze of digested insects. Did Monet put his hand in the ooze? Monet"s friend dropped out of sight for several years after that trip to Mount Elgon. Then, unexpectedly, she surfaced in a bar in Mombasa, where she was working as a prost.i.tute. A Kenyan doctor who had investigated the Monet case happened to be drinking a beer in the bar, and he struck up an idle conversation with her and mentioned Monet"s name. He was stunned when she said, "I know about that. I come from western Kenya. I was the woman with Charles Monet." He didn"t believe her, but she told him the story in enough detail that he became convinced she was telling the truth. She vanished after that meeting in the bar, lost in the warrens of Mombasa, and by now she has probably died of AIDS. Charles Monet returned to his job at the pump house at the sugar factory. He walked to work each day across the burned cane fields, no doubt admiring the view of Mount Elgon, and when the mountain was buried in clouds, perhaps he could still feel its pull, like the gravity of an invisible planet. Meanwhile, something was making copies of itself inside Monet. A life form had acquired Charles Monet as a host, and it was replicating.

THE HEADACHE BEGINS, typically, on the seventh day after exposure to the agent. On the seventh day after his New Year"s visit to Kitum Cave--January 8, 1980--Monet felt a throbbing pain behind his eyeb.a.l.l.s. He decided to stay home from work and went to bed in his bungalow. The headache grew worse. His eyeb.a.l.l.s ached, and then his temples began to ache, the pain seeming to circle around inside his head. It would not go away with aspirin, and then he got a severe backache. His housekeeper, Johnnie, was still on her Christmas vacation, and he had recently hired a temporary housekeeper. She tried to take care of him, but she really did not know what to do. Then, on the third day after his headache started, he became nauseated, spiked a fever, and began to vomit. His vomiting grew intense and turned into dry heaves. At the same time, he became strangely pa.s.sive. His face lost all appearance of life and set itself into an expressionless mask, with the eyeb.a.l.l.s fixed, paralytic, and staring. The eyelids were slightly droopy, which gave him a peculiar appearance, as if his eyes were popping out of his head and half-closed at the same time. The eyeb.a.l.l.s themselves seemed almost frozen in their sockets, and they turned bright red. The skin of his face turned yellowish, with brilliant starlike red speckles. He began to look like a zombie. His appearance frightened the temporary housekeeper. She didn"t understand the transformation in this man. His personality changed. He became sullen, resentful, angry, and his memory seemed to be blown away. He was not delirious. He could answer questions, although he didn"t seem to know exactly where he was. When Monet failed to show up for work, his colleagues began to wonder about him, and eventually they went to his bungalow to see if he was all right. The black-and-white crow sat on the roof and watched them as they went inside. They looked at Monet and decided that he needed to get to a hospital. Since he was very unwell and no longer able to drive a car, one of his co-workers drove him to a private hospital in the city of Kisumu, on the sh.o.r.e of Lake Victoria. The doctors at the hospital examined Monet, and could not come up with any explanation for what he might have some kind of bacterial infection, they gave him injections of antibiotics, but the antibiotics had no effect on his illness. The doctors thought he should go to Nairobi Hospital, which is the best private hospital in East Africa. The telephone system hardly worked, and it did not seem worth the effort to call any doctors to tell them that he was coming. He could still walk, and he had to get to Nairobi. They put him in a taxi to the airport, and he boarded a Kenya Airways flight. A hot virus from the rain forest lives within a twenty-four-hour plan flight from every city on earth. All of the earth"s cities are connected by a web of airline routes. The web is a network. Once a virus. .h.i.ts the net, it can shoot anywhere in a day-Paris, Tokyo, New York, Los Angeles, wherever planes fly. Charles Monet and the life form inside him had entered the net. The plane was a Fokker Friendship with propellers, a commuter aircraft that seats thirty-five people. It started its engines and took off over Lake Victoria, blue and sparkling, dotted with dugout canoes of fishermen. The Friendship turned and banked eastward, climbing over green hills quilted with tea plantations and small farms. The commuter flights hat drone across Africa are often jammed with people, and this flight was probably full. The plane climbed over belts of forest and cl.u.s.ters of round huts and villages with tin roofs. The land suddenly dropped away, going down in shelves and ravines, and changed in color from green to brown. The plane was crossing the Eastern Rift Valley. The pa.s.sengers looked out the windows at the place where the human species was born. They saw specks of huts cl.u.s.tered inside circles of thornbush, with cattle trails radiating from the huts. The propellers moaned, and the Friendship pa.s.sed through cloud streets, lines of puffy Rift clouds, and began to bounce and sway. Monet became airsick. The seats are narrow and jammed together on these commuter airplanes, and you notice everything that is happening inside the cabin. The cabin is tightly closed, and the air recirculates. If there are any smells in the air, you perceive them. You would not have been able to ignore the man who was getting sick. He hunches over in his seat. There is something wrong with him, but you can"t tell exactly what is happening. He is holding an airsickness bag over his mouth. He coughs a deep cough and regurgitates something into the bag. The bag swells up. Perhaps he glances around, and then you see that his lips are smeared with something slippery and red, mixed with black specks, as if he has been chewing coffee grounds. His eyes are the color of rubies, and his face is an expressionless ma.s.s of bruises. The red spots, which a few days before had started out as starlike speckles, expanded and merged into huge, spontaneous purple shadows; his whole head is turning black-and-blue. The muscles of his face droop. The connective tissue in his face is dissolving, and his face appears to hang from underlying bone, as if the face is detaching itself from the skull. He opens his mouth and gasps into the bag, and the vomiting goes on endlessly. It will not stop, and he keeps bringing up liquid, long after his stomach should have been empty. The airsickness bag fills up to the brim with a substance known as vomit negro, or the black vomit. The black vomit is not really black; it is a speckled liquid of two colors, black and red, a stew of tarry granules mixed with fresh red arterial blood. It is hemorrhage, and it smells like a slaughterhouse. The black vomit is loaded with virus. It is highly infective, lethally hot, a liquid that smell of the vomit negro fills the pa.s.senger cabin. The airsickness bag is br.i.m.m.i.n.g with black vomit, so Monet closes the bag and rolls up the top. The bag bulging and softening, threatening to leak, and he hands it to a flight attendant. When a hot virus multiplies in a host, it can saturate the body with virus particles, from the brain to the skin. The military experts then say that the virus has undergone "extreme amplification". This is not something like the common cold. By the time an extreme amplification peaks out, an eyedropper of the victim"s blood may contain a hundred million particles of virus. During this process, the body is partly transformed into virus particles. In other words, the host is possessed by a life form that is attempting to convert the host into itself. The transformation is not entirely successful, however, and the end result is a great deal of liquefying flesh mixed with virus, a kind of biological accident. Extreme amplification has occurred in Monet, and the sign of it is the black vomit. He appears to be holding himself rigid, as if any movement would rupture something inside him. His blood is clotting up-his bloodstream is throwing clots, and the clots are lodging everywhere. His liver, kidneys, lungs, hands, feet, and head are becoming jammed with blood clots. In effect, he is having a stroke through the whole body. Clots are acc.u.mulating in his intestinal muscles, cutting off the blood supply to his intestines. The intestinal muscles are beginning to die, and the intestines are starting to go slack. He doesn"t seem to be fully aware of pain any longer because the blood clots lodged in his brain are cutting off blood flow. His personality is being wiped away by brain damage. This is called depersonalization, in which the liveliness and details of character seem to vanish. He is becoming an automaton. Tiny spots in his brain are liquefying. The higher functions of consciousness are winking out first, leaving the deeper parts of the brain stem (the primitive rat brain, the lizard brain) still alive and functioning. It could be said that the who of Charles Mont has already died while the what of Charles Monet continues to live. The vomiting attack appears to have broken some blood vessels in his nose-he gets a nosebleed. The blood comes from both nostrils, a shining, cloudless, arterial liquid that drips over his teeth and chin. This blood keeps running, because the clotting factors have been used up. A flight attendant gives him some paper towels, which he uses to stop up his nose, but the blood still won"t coagulate, and the towels soak through. When a man is ill in an airline seat next to you, you may not want to embarra.s.s him by calling attention to the problem. You say to yourself that this man will be all right. Maybe he doesn"t travel well in airplanes. He is airsick, the poor man, and people do get nosebleeds in airplanes, the air is so dry and thin ... and you ask him, weakly, if there is anything you can do to help. He does not answer, or he mumbles words you can"t understand, so you try to ignore it, but the flight seems to go on forever. Perhaps the flight attendants offer to help him. But victims of this type of hot virus have changes in behavior that can render them incapable of responding to an offer of help. They become hostile, and don"t want to be touched. They don"t want to speak. They answer questions with grunts or monosyllables. They can"t seem to find words. They can tell you their name, but they can"t tell you the day of the week or explain what has happened to them. The Friendship drones through the clouds, following the length of the Rift Valley, and Monet slumps back in the seat, and now he seems to be dozing ... Perhaps some of the pa.s.sengers wonder if he is dead. No, no, he is not dead. He is moving. His red eyes are open and moving around a little bit. It is late afternoon, and the sun is falling down into the hills to the west of the Rift Valley, throwing blades of light in all directions, as if the sun is cracking up on the equator. The Friendship makes a gentle turn and crosses the eastern scarp of the Rift. The land rises higher and changes in color from brown to green. The Ngong Hills appear under the right wing, and the plane, now descending, pa.s.ses over parkland dotted with zebra and giraffes. A minute later, it lands at Jomo Kenyatta International Airport. Monet stirs himself. He is still able to walk. He stands up, dripping. He stumbles down the gangway onto the tarmac. His shirt is a red mess. He carries no luggage. His only luggage is internal, and it is a load of amplified virus. Monet has ben transformed into a human virus bomb. He walks slowly into the airport terminal and through the building and out to a curving road where taxis are always parked. The taxi drivers surround him--"Taxi?" "Taxi?" "Nairobi ... Hospital," he mumbles. One of them helps him into a car. Nairobi taxi drivers like to chat with their fares, and this one probably asks if he is sick. The answer should be obvious. Monet"s stomach feels a little better now. It is heavy, dull, and bloated, as if he has eaten a meal, rather than empty and torn and on fire. The taxi pulls onto the Uhuru Highway and heads into Nairobi. It goes through gra.s.sland studded with honey-acacia trees, and it goes past factories, and then it comes to a rotary and enters the bustling street life of Nairobi. Crowds are milling on the shoulders of the road, women walking on beaten dirt pathways, men loitering, children riding bicycles, a man repairing shoes by the side of the road, a tractor pulling a wagonload of charcoal. The taxi turns left onto the Ngong Road and goes past a city park and up a hill, past lines of tall blue-gum trees, and it turns up a narrow road and goes past a guard gate and enters the grounds of Nairobi Hospital. It parks at a taxi stand beside a flower kiosk. A sign by a gla.s.s door says CASUALTY DEPT. Monet hands the driver some money and gets out of the tax and opens the gla.s.s door and goes over to the reception window and indicates that he is very ill. He has difficulty speaking. The man is bleeding, and they will admit him in just a moment. He must wait until a doctor can be called, but the doctor will see him immediately, not to worry. He sits down in the waiting room. It is a small room lined with padded benches. The clear, strong ancient light of East Africa pours through a row of window and falls across a table heaped with soiled magazines, and makes rectangles on a pebbled gray floor that has a drain in the center. The room smells vaguely of woodsmoke and sweat, and it is jammed with bleary-eyed people, Africans and Europeans sitting shoulder to shoulder. There is always someone in Casualty who has a cut and is waiting for st.i.tches. People wait patiently, holding a washcloth against the scalp, holding a bandage pressed around a finger, and you may see a spot of blood on the cloth. So Charles Monet is sitting on a bench in casualty, and he does not look very much different from someone else in the room, except for his bruised, expressionless face and his red eyes. A sign on the wall warns patients to watch out for purse thieves, and another sign says: PLEASE MAINTAIN SILENCE YOUR COOPERATION WILL BE APPRECIATED.

NOTE: THIS IS A CASUALTY DEPARTMENT. EMERGENCY CASES WILL BE TAKEN IN PRIORITY. YOU MAY BE REQUIRED TO WAIT FOR SUCH CASES BEFORE RECEIVING ATTENTION.

Monet maintains silence, waiting to receive attention. Suddenly he goes into the last phase. The human virus bomb explodes. Military biohazard specialists have ways of describing this occurrence. They say that the victim has "crashed and bled out". Or more politely they say that the victim has "gone down". He becomes dizzy and utterly weak, and his spine goes limp and nerveless and he loses all sense of balance. The room is turning around and around. He is going into shock. He leans over, head on his knees, and brings up an incredible quant.i.ty of blood from his stomach and spills it onto the floor with a gasping groan. He loses consciousness and pitches forward onto the floor. The only sound is a choking in his throat as he continues to vomit while unconscious. Then come a sound like bedside being torn in half, which is the sound of his bowels opening and venting blood from sloughed his gut. The linings of his intestines have come off and are being expelled along with huge amount of blood. Monet has crashed and is bleeding out. The other patients in the waiting room stand up and move away from the man on the floor, calling for a doctor. Pools of blood spread out around him, enlarging rapidly. Having destroyed its host, the agent is now coming out of every orifice, and is "trying" to find a new host.

JUMPER.

1980 JANUARY 15.

NURSES AND AIDES came running, pushing a gurney along with them, and they lifted Charles Monet onto the gurney and wheeled him into the intensive care unit at Nairobi Hospital. A call for a doctor went out over the loudspeakers: a patient was bleeding in the ICU. A young doctor named Shem Musoke ran to the scene. Dr. Musoke was widely considered to be one of the best young physicians at the hospital, an energetic man with a warm sense of humor, who worked long hours and had a good feel for emergencies. He found Monet lying on the gurney. He has no idea what was wrong with the man, except that he was obviously having some kind of ma.s.sive hemorrhage. There was no time to try to figure out what has caused it. He was having difficulty breathing-and then his breathing stopped. He had inhaled blood and had a breathing arrest. Dr. Musoke felt for a pulse. It was weak and sluggish. A nurse ran and fetched a laryngoscope, a tube that can be used to open a person"s airway. Dr. Musoke ripped open Monet"s shirt so that he could observe any rise and fall of the chest, and he stood at the head of the gurney and bent over Monet"s face until he was looking directly into his eyes, upside down. Monet stared redly at Dr. Musoke, but there was no movement in the eyeb.a.l.l.s, and the pupils were dilated. Brain damage: n.o.body home. His nose was b.l.o.o.d.y and his mouth was b.l.o.o.d.y. Dr. Musoke tilted the patient"s head back to open the airway so that he could insert the laryngoscope. He was not wearing rubber gloves. He ran his finger around the patient"s tongue to clear the mouth of debris, sweeping out mucus and blood. His hands became greasy with black curd. The patient smelled of vomit and blood, but this was nothing new to Dr. Musoke, and he concentrated on his work. He leaned down until his face was a few inches away from Monet"s face, and he looked into Monet"s mouth in order to judge the position of the scope. Then he slid the scope over Monet"s tongue and pushed the tongue out of the way so that he could see down the airway past the epiglottis, a dark hole leading inward to the lungs. He pushed the scope into the hole, peering into the instrument. Monet suddenly jerked and thrashed. Monet vomited. The black vomit blew up around the scope and out of Monet"s mouth. Black-and-red fluid spewed into the air, showering down over Dr. Musoke. It struck him in the eyes. It splattered over his white coat and down his chest, marking him with strings of red slime dappled with dark flecks. It landed in his mouth. He repositioned his patient"s head and swept the blood out of the patient"s mouth with his fingers. The blood had covered Dr. Musoke"s hands, wrists and forearms. It had gone everywhere-all over the gurney, all over Dr. Musoke, all over the floor. The nurses in the intensive care unit couldn"t believe their eyes, and they hovered in the background, not knowing quite what to do. Dr. Musoke peered down into the airway and pushed the scope deeper into the lungs. He saw that the airways were b.l.o.o.d.y. Air rasped into the man"s lungs. The patient had began to breathe again. The patient was apparently in shock from loss of blood. He had lost so much blood that he was becoming dehydrated. The blood had come out of practically every opening in his body. There wasn"t enough blood left to maintain circulation, so his heartbeat was very sluggish, and blood pressure was dropping toward zero. He needed a blood transfusion. A nurse brought a bag of whole blood. Dr. Musoke hooked the bag on a stand an inserted the needled into the patient"s arm. There was something wrong with the patient"s veins; his blood poured out around the needle. Dr. Musoke tried again, putting the needle into another place in the patient"s arm and probing for the vein. Failure. More blood poured out. At every place in the patient"s arm where he stuck the needle, the vein broke apart like cooked macaroni and spilled blood, and the blood ran from the punctures down the patient"s arm and wouldn"t coagulate. Dr. Musoke abandoned his efforts to give his patient a blood transfusion for fear that the patient would bleed to death out of the small hole in his arm. The patient continued to bleed from the bowels, and these hemorrhages were now as black as pitch. Monet"s coma deepened, and he never regained consciousness. He died in the intensive care unit in the early hours of the morning. Dr. Musoke stayed by his bedside the whole time. They has no idea what had killed him. It was unexplained death. They opened him up for an autopsy and found that his kidneys were destroyed and that his liver was dead. His liver had ceased functioning several days before he died. It was yellow, and parts of it had liquefied-it looked like the liver of a three-day-old cadaver. It was as if Monet had become a corpse before his death. Sloughing of the gut, in which the intestinal ling comes off, is another effect that is ordinarily seen in a corpse that is days old. What, exactly, was the cause of death? It was impossible to say because there were too many possible causes. Everything had gone wrong inside this man, absolutely everything, any one of which could have been fatal: the clotting, the ma.s.sive hemorrhages, the liver turned into pudding, the intestines full of blood. Lacking words, categories, or language to describe what had happened, they called it, finally, a case of "fulminating liver failure". His remain were placed in a waterproof bag and, according to one account, buried locally. When I visited Nairobi, years later, no one remembered where the grave was.

1980 JANUARY 24.

NINE DAYS AFTER the patient vomited into Dr. Shem Musoke"s eyes and mouth, Musoke developed an aching sensation in his back. He was not p.r.o.ne to backaches-really, he had never had a serious backache, but he was approaching thirty, and it occurred to him that he was getting into the time of life when some men begin to get bad backs. He had been driving himself hard these past few weeks. He had been up all night with a patient who had heart problems, and then, the following night, he had been up most of the night with that Frenchman with hemorrhages who ha come from somewhere upcountry. So he had been going nonstop for days without sleep. He hadn"t thought much about the vomiting incident, and when the ache began to spread through his body, he still didn"t think about it. Then, when he looked in a mirror, he noticed that his eyes were turning red. Red eyes-he began to wonder if he had malaria. He had a fever now, so certainly he had some kind of infection. The backache had spread until all the muscles in his body ached badly. He started taking malaria pills, but they didn"t do any good, so he asked one of the nurses to give him an injection of an antimalarial drug. 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 cam through the foam. He leaked blood like a sponge. They had to suction off a lot of blood, 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 Inst.i.tute of Virology in Sandringham, South Africa, and to the Centers for Disease Control in Atlanta, Georgia, U.S.A. Then he waited for results.

DIAGNOSIS.

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 Monet and Musoke cases. Silverstein is a slender, short man in his late forties, with a mustache and gla.s.ses, and he has an alert, quick gaze. Although he is an American, his voice carries a hint of 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, 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 n.o.bility. 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 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 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 shipment 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 human population of the city. This is an example of virus amplification. The first person known to be infected with Marburg agent was a man called Klaus F., an employee at 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 virus, held at the University of Marburg in 1970. In the book, we learn that The monkey-keeper HEINRICH P. came back from his holiday on August 13th 1967 and did his job of killing monkeys from 14th-23rd. The first symptoms appeared on August 21st. The laboratory a.s.sistant RENATE L. broke a test-tube that was to be sterilized, which had contained infected material, on August 28th, and fell ill on September 4th 1967.

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 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 train 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 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 fellout 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, semirotten t.e.s.t.i.c.l.es. One of the worst cases of this appeared in a morgue attendant who had handled Marburg-infected bodies. The virus also lingered in the fluid inside the eyeb.a.l.l.s of some victims for many months. No one knows why Marburg has a special affinity for the t.e.s.t.i.c.l.es and the eyes. One man infected his wife with Marburg through s.e.xual intercourse. Doctors noticed that the Marburg agent had a strange effect on the brain. "Most of the patients showed a sullen, slight 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 named 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 ma.s.sive, 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 kin 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. 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 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. After making a number of telephone calls, I finally located Mr. Jones in a town in England, where today he is working as a veterinary consultant. He said to me: "All that animals got, before they were shipped off, was a visual inspection." "By whom?" I asked. "By me," he said. "I inspected them to see that they appeared normal. On occasion, with some of these shipments, one or two animals were injured or had skin leisons." His method was to pick out the sick-looking ones, which were removed from the shipment and presumably killed before the remaining healthy-looking animals were loaded onto the plane. When, a few weeks later, the monkeys started the outbreak in Germany, Mr. Jones felt terrible. "I was appalled, because I had signed the export certificate," he said to me. "I feel now that I have the deaths of these people on my hands. But that feeling suggests I could have done something about it. There was no way I could have known." He is right about that: the virus was then unknown to science, and as few as two or three not-visibly-sick animals could have started the outbreak. One concludes that the man should not be blamed for anything. The story becomes more disturbing. He went on: "The sick ones were being killed, or so I thought." But later he learned that they weren"t being killed. The boss of the company was having the sick monkeys put in boxes and shipped out to a small island in Lake Victoria, where they were released. With so many sick monkeys running around it, the island could have become a focus for monkey viruses. It could have been a hot island, an isle of plagues. "Then, if this guy was a bit short of monkeys, he went out to the island and caught a few, unknown to me." Mr. Jones thinks it is possible that the Marburg agent had established itself on the hot island, and was circulating among the monkeys there, an that some of the monkeys which ended up in Germany had actually come from that island. But when the WHO team came later to investigate, "I was told by my boss to say nothing unless asked." As it turned out, no one asked Mr. Jones any questions-he says he never met the WHO team. The fact that the team apparently never spoke with him, the monkey inspector, "was bad epidemiology but good politics," he remarked to me. If it had been revealed that the monkey trader was shipped off suspect monkeys collected on a suspect island, he could have been put out of business, and Uganda would have lost a source of valuable foreign cash. Shortly after the Marburg outbreak, Mr. Jones recalled a fact that began to seem important to him. Between 1962 and 1965 he had been stationed in eastern Uganda, on the slopes of Mount Elgon, inspecting cattle for disease. At some time during that period, local chiefs told him that the people who lived on the north side of the volcano, along the Greek River, were suffering from a disease that caused bleeding, death, and "a particular skin rash"-and that monkeys in the area were dying of a similar disease. Mr. Jones did not pursue the rumors, and was never able to confirm the nature of the disease. But it seems possible that in the years preceding the outbreak of Marburg virus in Germany, a hidden outbreak of the virus occurred on the slopes of Mount Elgon.

MR. JONES"S PERSONAL VISION of the Marburg outbreak reminds me of a flashlight pointed down a dark hole. It gives a narrow but startling view of the larger phenomenon of the origin and spread of tropical viruses. He told me that some of the Marburg monkeys were trapped in a group of islands in Lake Victoria known as the Sese Islands. The Senses are a low-lying forested archipelago in the northwestern part of Lake Victoria, an easy boat ride from Entebbe. The isle of plagues may have been situated among the Senses or near them. Mr. Jones does not recall the name of the hot island. He says it is close to Entebbe. At any rate, Mr. Jones"s then-boss, the Entebbe monkey trader, had arranged a deal with villagers in the Sese Islands to buy monkeys from them. They regarded the monkeys as pests and were happy to get rid of them, especially for money. So the trader was obtaining wild monkeys from Sese Islands, and if the animals proved to be sick, he was releasing them on another island somewhere near Entebbe. And some monkeys from the isle of plagues seemed to be ending up in Europe. In papyrus reeds and desolate flatlands on the western sh.o.r.e of Lake Victoria facing the Sese Islands, there is a fishing village called Kasensero. You can see the Sese Islands from the village. Kasensero was one of the first places in the world where AIDS appeared. Epidemiologists have since discovered that the northwestern sh.o.r.e of Lake Victoria was one of the initial epicenters of AIDS. It is generally believed that AIDS came originally from African primates, from monkeys and apes, and that it somehow jumped out of these animals into the human race. It is thought that the virus went through a series of very rapid mutations at the time of its jump from primates to humans, which enabled it to establish itself successfully in people. In the years since AIDS virus emerged, the village of Kasensero has been devastated. The virus has killed a large portion of the inhabitants. It is said that other villages along the sh.o.r.es of Lake Victoria have been essentially wiped off the map. The villagers of Kasensero are fishmen who were, and are, famous as smugglers. In their wooden boats and motorized canoes they ferried illegal goods back and forth across the lake, using the Sese Islands as hiding places. One can guess that if a monkey trader were moving monkeys around Lake Victoria, he might call on the Kasensero smugglers or on their neighbors. One general theory for the origin of AIDS goes that, during the late nineteen-sixties, a new and lucrative business grew up in Africa, the export of primates to industrialized countries for use in medical research. Uganda was one of the biggest sources of these animals. As the monkey trade was established throughout central Africa, the native workers in the system, the monkey trappers and handlers, were exposed to large numbers of wide monkeys, some of which were carrying unusual viruses. These animals, in turn, were being jammed together in cages, exposed to one another, pa.s.sing viruses back and forth. furthermore, different species of monkeys were mixed together. It was a perfect setup for an outbreak of a virus that could jump species. It was also a natural laboratory for rapid virus evolution, and possibly it led to the creation of HIV. Did HIV crash into the human race as a result of the monkey trade? Did AIDS come from an island in Lake Victoria? A hot island? Who knows. When you begin probing into the origins of AIDS and Marburg, the light fails and things go dark, but you sense hidden connections. Both viruses seem part of a pattern.

WHEN HE LEARNED what Marburg virus does to human being, Dr. David Silverstein persuaded the Kenyan health authorities to shut down Nairobi Hospital. For a week, patients who arrived at the doors were turned away, while sixty seven people were quarantined inside the hospital, most medical staff. They included the doctor who had done autopsy on Monet, nurses who had attended Monet or Dr. Musoke, the surgeons who had operated on Musoke, and aides and technicians who had handled any secretions from either Monet or Musoke. It turned out that a large part of the hospital"s staff had direct contact with either Monet or Musoke or with blood samples and fluids that came from the two patients. The surgeons who had operated on Musoke, remembering only too well that they had been "up to the elbows in blood", sweated in quarantine for two weeks while they wondered if they were going to break with Marburg. A single human virus bomb had walked into the Casualty waiting room and exploded there, and the event had put the hospital out of business. Charles Monet had been an Exocet missile that stuck the hospital below the water line. Dr. Shem Musoke survived his encounter with a hot agent. Ten days after he fell sick, the doctors noticed a change for the better. Instead of merely lying in bed in a pa.s.sive state, he became disoriented and angry and refused to take medicine. One day, a nurse was trying to turn him over in bed, and he waved his fist at her and cried, "I have a stick, and I will beat you." It was around that time that he began to get better, and after many days his fever subsided and his eyes cleared; his mind and personality came back, and he recovered slowly but completely. Today he is one of the leading physicians at Nairobi Hospital, where he practices as a member of David Silverstein"s group. One day I interviewed him, and he said to me that he has almost no memory of the weeks he was infected in Marburg. "I only remember bits and pieces," he said. "I remember having major confusion. I remember, before my surgery, that I walked out of my room with my IV drip hanging out of me. I don"t remember much of the pain. The only pain I can talk about is the muscle ache and the lower-back ache. And I remember him throwing up on me." n.o.body else at the hospital developed a proven case of Marburg-virus disease. When a virus is trying, so to speak, to crash into the human species, the warning sign may be a spattering of breaks at different times and places. These are microbreaks. What had happened at Nairobi Hospital was an isolated emergence, a microbreak of a rain-forest virus with unknown potential to start an explosive chain of lethal transmission in the human race. Tubese of Dr. Musoke"s blood went to laboratories around the world so that they could have samples of living Marburg for their collections of life forms. The Marburg in his blood had come from Charles Monet"s black vomit and perhaps originally from Kitum Cave. Today this particular strain of Marburg virus is known as Musoke strain. Some of it ended in gla.s.s vials in freezers owned by the United States Army, where it was kept immortal in a zoo of hot agents.

A WOMAN AND A SOLDIER.

1983 SEPTEMBER 25, 1800 HOURS.

THURMONT, MARYLAND, nearly four years after the death of Charles Monet. Evening, A typical American town. On Catoctin Mountain, a ridge of the Appalachians that runs north to south through the western part of the state, the trees were brightening into soft yellows and golds. Teenagers drove their pickup trucks slowly along the streets of the town, looking for something to happen, wishing that the summer had not ended. Faint smells of autumn touched the air, the scent of ripening apples, a soreness of dead leaves, cornstalks drying in the fields. In the apple groves at the edge of town, flocks of grackles settled into the branches for the night, squawking. Headlights streamed north on the Gettysburg road. In the kitchen of a Victorian house near the center of town, Major Nancy Jaax, a veterinarian in the United States Army, stood at a counter making dinner for her children. She slid a plate into the microwave oven and pushed a b.u.t.ton. Time to nuke up some chicken for the kids. Nancy Jaax wore sweatpants and a T-shirt, and she was barefoot. Her feet had calluses on them, the result of martial-arts training. She had way auburn hair, which was cut above the shoulders, and greenish eyes. Her eyes were actually two colors, green with an inner rim around the iris was amber. She was a former homecoming queen from Kansas-Miss Agriculture, Kansas State. She had a slender, athletic build, and she displayed quick motions, flickery gestures, with her arms and hands. Her children were restless and tired, and she worked as fast as she could to fix the dinner. Jaime, who was five, hung on Nancy"s leg. She grabbed the leg of Nancy"s sweatpants and pulled, and Nancy lurched sideways, and then Jaime pulled the other way, and Nancy lurched to the other side. Jaime was short for her age had greenish eyes, like her mother. Nancy"s son, Jason, who was seven, was watching television in the living room. He was rail thin and quiet, and when he grew up he would probably be tall, like his father. Nancy"s husband,