Outbreak (4 page)

After several glasses of good wine, Marissa was more talkative than normal. She felt a twinge of embarrassment when she realized that the entire table was listening to her description of her childhood in Virginia. She told herself to shut up and smile, and she was pleased when the conversation switched to the sorry state of American medicine and how prepaid health-care groups were eroding the foundations of private practice. Remembering the furs and jewels, Marissa didn't feel that those present were suffering too much.

"How about the CDC?" asked Dr. Hayward, looking across at Cyrill. "Have you been experiencing budgetary constraints?"

Cyrill laughed cynically, his smile forming deep creases in his cheeks. "Every year we have to do battle with the Office of Management and Budget as well as the House Appropriations Committee. We've lost five hundred positions due to budgetary cuts."

Dr. Jackson cleared his throat: "What if there were a serious outbreak of influenza like the pandemic of 1917-1918. Assuming your

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department would be involved, do you have the manpower for such an eventuality?"

Cyrill shrugged. "It depends on a lot of variables. If the strain doesn't mutate its surface antigens and we can grow it readily in tissue culture, we could develop a vaccine quite quickly. How quickly, I'm not sure. Tad?"

"A month or so," said Tad, "if we were lucky. More time to produce enough to make a significant difference."

"Reminds me of the swine flu fiasco a few years ago," interjected Dr. Hayward.

"That wasn't the CDC's fault," said Cyrill defensively. "There was no doubt about the strain that appeared at Fort Dix. Why it didn't spread is anybody's guess."

Marissa felt a hand on her shoulder. Turning, she found herself looking at one of the black-dressed waitresses.

"Dr. Blumenthal?" whispered the girl.

"Yes."

"There is a phone call for you."

Marissa glanced down the table at Ralph, but he was busy talking with Mrs. Jackson. She excused herself and followed the girl to the kitchen. Then it dawned on her, and she felt a stirring of fear, like the first time she had been called at night as an intern: It had to be the CDC. After all, she was on call and she'd dutifully left Ralph's number. No one else knew she was there.

"Dr. Blumenthal?" asked the CDC operator, when Marissa picked up the phone.

The call was switched to the duty officer. "Congratulations," he said jovially. "There has been an epidemic aid request. We had a call from the California State Epidemiologist, who would like CDC help on a problem in L.A. It's an outbreak of unknown but apparently serious illness in a hospital called the Richter Clinic. We've gone ahead and made a reservation for you on Delta's flight to the coast that leaves at 1:10 A.M. We've arranged hotel accommodations at a place called the Tropic Motel. Sounds divine. Anyway, good luck!"

Replacing the receiver, Marissa left her hand on the phone for a moment while she caught her breath. She didn't feel prepared at all. Those poor, unsuspecting people in California had called the CDC expecting to get an epidemiologic expert, and instead, they were going to get her, Marissa Blumenthal. All five feet of her. She made her way back to the dining room to excuse herself and say good-bye.

2

January 21

BY THE TIME MARISSA had gotten her suitcase from the baggage carousel, waited for the rent-a-car van, gotten the rent-a-car (the first one wouldn't start), and had somehow managed to find the Tropic Motel, the sky had begun to lighten.

As she signed in, she couldn't help thinking of Roger. But she wouldn't call. She'd promised herself that much several times on the flight.

The motel was depressing, but it didn't matter. Marissa didn't think she'd be spending much time there. She washed her hands and face, combed her hair and replaced her barrette. With no other plausible reason for delay, she returned to the rent-a-car and set out for the Richter Clinic. The palms of her hands were damp against the steering wheel.

The clinic was conveniently situated on a wide thoroughfare. There were few cars at that time of morning. Marissa pulled into a parking garage, took a ticket and found a spot near the entrance. The entire structure was modern, including the garage, the clinic, and what Marissa guessed was the hospital, which appeared to be seven stories tall. Getting out of the car, she stretched, then lifted out her briefcase. In it were her class notes from the epidemiology portion of the introductory course-as if that would be any help-a note pad, pencils, a small textbook on diagnostic virology, an extra lipstick and a pack of chewing gum. What a joke.

Once inside, Marissa noted the familiar hospital odor of disinfectant-a smell that somehow calmed her and made her feel instantly at home. There was an information booth, but it was empty. She asked a maintenance man mopping the floor how to get to the hospital wing, and he pointed to a red stripe on the floor. Marissa followed it to the emergency room. There was little activity there, with few patients in the waiting room and only two nurses behind the main desk. Marissa sought out the on-call doctor and explained who she was.

"Oh, great!" said the ER doctor enthusiastically. "Are we glad you're here! Dr. Navarre has been waiting all night for you. Let me get him."

Marissa absentmindedly played with some paper clips. When she looked up, she realized the two nurses were staring at her. She smiled and they smiled back.

"Can I get you some coffee?" asked the taller of the two.

"That would be nice," said Marissa. In addition to her basic anxiety, she was feeling the effects of only two hours of fitful sleep on the flight from Atlanta.

Sipping the hot liquid, Marissa recalled the Berton Roueche medical detective stories in The New Yorker. She wished that she could be involved in a case like the one solved by John Snow, the father of modern epidemiology: A London cholera epidemic was aborted when Snow deductively isolated the problem to a particular London water pump. The real beauty of Snow's work was that he did it before the germ theory of disease was accepted. Wouldn't it be wonderful to be involved in such a clear-cut situation?

The door to the on-call room opened, and a handsome, black-haired man appeared. Blinking in the bright ER light, he came directly toward Marissa. The corners of his mouth pulled up in a big smile. "Dr. Blumenthal, we are so glad to see you. You have no idea."

As they shook hands, Dr. Navarre gazed down at Marissa. Standing next to her, he was momentarily taken aback by her diminutive size and youthful appearance. To be polite, he inquired about her flight and asked if she was hungry.

"I think it would be best to get right down to business," said Marissa.

Dr. Navarre readily agreed. As he led Marissa to the hospital conference room, he introduced himself as chief of the department of medicine. This news didn't help Marissa's confidence. She recognized that Dr. Navarre undoubtedly knew a hundred times more than she about infectious disease.

Motioning for Marissa to sit at the round conference table, Dr. Navarre picked up the phone and dialed. While the call was going through, he explained that Dr. Spenser Cox, the State Epidemiologist was extremely eager to talk to Marissa the moment she'd arrived.

Wonderful, thought Marissa, forcing a weak smile.

Dr. Cox sounded equally as happy as Dr. Navarre that Marissa was there. He explained to her that unfortunately he was currently embroiled in a problem in the San Francisco Bay area involving an outbreak of hepatitis B that they thought could be related to AIDS.

"I assume," continued Dr. Cox, "that Dr. Navarre has told you that the problem at the Richter Clinic currently involves only seven patients."

"He hasn't told me anything yet," said Marissa.

"I'm sure he is just about to," said Dr. Cox. "Up here, we have almost five hundred cases of hepatitis B, so you can understand why I can't come down there immediately."

"Of course," said Marissa.

"Good luck," said Dr. Cox. "By the way, how long have you been with the CDC?"

"Not that long," admitted Marissa.

There was a short pause. "Well, keep me informed," said Dr. Cox.

Marissa handed the receiver back to Dr. Navarre, who hung up. "Let me bring you up to date," he said, switching to a standard medical monotone as he pulled some three-by-five cards from his pocket. "We have seven cases of an undiagnosed, but obviously severe, febrile illness characterized by prostration and multi-system involvement. The first patient to be hospitalized happens to be one of the cofounders of the clinic, Dr. Richter himself. The next, a woman from the medical records department." Dr. Navarre began placing his three-by-five cards on the table. Each one represented a patient. He organized them in the order in which the cases had presented themselves.

Discreetly snapping open her briefcase without allowing Dr. Navarre to see what it contained, Marissa extracted her note pad and a pencil. Her mind raced back to the courses she'd recently completed, remembering that she needed to break the information down into understandable categories. First the illness: Was it really something new? Did a problem really exist? That was the province of the simple 2 x 2 table and some rudimentary statistics. Marissa knew she had to characterize the illness even if she couldn't make a specific diagnosis. The next step would be to determine host factors of the victims, such as age, sex, health, eating habits, hobbies, etc., then to

determine time, place and circumstances in which each patient displayed initial symptoms, in order to learn what elements of commonality existed. Then there would be the question of transmission of the illness, which might lead to the infectious agent. Finally, the host or reservoir would have to be erradicated. It sounded so easy, but Marissa knew it would be a difficult problem, even for someone as experienced as Dubchek.

Marissa wiped her moist hand on her skirt, then picked up her pencil once more. "So," she said, staring at the blank page. "Since no diagnosis has been made, what's being considered?"

"Everything," said Dr. Navarre.

"Influenza?" asked Marissa, hoping she wasn't sounding overly simplistic.

"Not likely," said Dr. Navarre. "The patients have respiratory symptoms but they do not predominate. Besides, serological testing has been negative for influenza virus in all seven patients. We don't know what they have, but it is not influenza."

"Any ideas?" asked Marissa.

"Mostly negatives," said Dr. Navarre. "Everything we've tested has been negative: blood cultures, urine cultures, sputum cultures, stool cultures, even cerebrospinal fluid cultures. We thought about malaria and actually treated for it, though the blood smears were negative for the parasites. We even treated for typhoid, with either tetracycline or chloramphenicol, despite the negative cultures. But, just like with the antimalarials, there was no effect whatsoever. The patients are all going downhill no matter what we do."

"You must have some kind of differential diagnosis," said Marissa. "Of course," responded Dr. Navarre. "We've had a number of infectious disease consults. The consensus is that it is a viral problem, although leptospirosis is still a weak contender." Dr. Navarre searched through his index cards, then held one up. "Ah, here are the current differential diagnoses: leptospirosis, as I mentioned; yellow fever; dengue; mononucleosis; or, just to cover the bases, some other enteroviral, arboviral or adenoviral infection. Needless to say, we've made about as much progress in the diagnostic realm as the therapeutic."

"How long has Dr. Richter been hospitalized?" asked Marissa.

"This is his fifth day. I think you should see the patients to have an idea of what we are dealing with." Dr. Navarre stood up without waiting for Marissa's response. She found she had to trot to keep up with him. They went through swinging doors and entered the hospital proper. Nervous as she was, Marissa could not help being impressed by the luxurious carpeting and almost hotellike decor.

She got on the elevator behind Dr. Navarre, who introduced her to an anesthesiologist. Marissa returned the man's greeting, but her thoughts were elsewhere. She was certain that her seeing the patients at that moment was not going to accomplish anything except to make her feel "exposed." This issue had not occurred to her while taking the introductory course back in Atlanta. Suddenly it seemed like a big problem. Yet what could she say?

They arrived at the nurses' station on the fifth floor. Dr. Navarre took the time to introduce Marissa to the night staff, who were making their initial preparations to change shifts.

"All seven patients are on this floor," said Dr. Navarre. "It has some of our most experienced personnel. The two in critical condition are in separate cubicles in the medical intensive-care unit just across the hall. The rest are in private rooms. Here are the charts." With an open palm, he thumped a pile stacked on the corner of the counter top. "I assume you'd like to see Dr. Richter first." Dr. Navarre handed Richter's chart to Marissa.

The first thing she looked at was the "vital-sign" sheet. Beginning his fifth hospital day, she noticed that the doctor's blood pressure was falling and his temperature was rising. Not a good omen. Rapidly she perused the chart. She knew that she'd have to go over it carefully later. But even a cursory glance convinced her that the workup had been superb, better than she could have done herself. The laboratory work had been exhaustive. Again she wondered what in God's name she was doing there pretending to be an authority.

Going back to the beginning of the chart, Marissa read the section entitled "history of the present illness." Something jumped out at her right away. Six weeks previous to the onset of symptoms Dr. Richter had attended an ophthalmological convention in Nairobi, Kenya.

She read on, her interest piqued. One week prior to his illness, Dr. Richter had attended an eyelid surgery conference in San Diego. Two days prior to admission he'd been bitten by a Cercopitheceus aethiops, whatever the hell that was. She showed it to Dr. Navarre.

"It's a type of monkey," said Dr. Navarre. "Dr. Richter always has a few of them on hand for his ocular herpes research."