Panic in Level 4

1. Disturbed Forest

MONTHS LATER, when the epidemiologists finally arrived, they traced the threads of the horror back to one man, Patient Zero, who became known only by his initials, G.M. The threads converged on one little spot in the world. It was a sinuous patch of forest called Mbwambala. Mbwambala is a fragment of disturbed woodland about three miles long and half a mile wide that wanders along a small stream about six miles southeast of the city of Kikwit, in the Democratic Republic of the Congo. G.M. was forty-two years old at the time of his death. He lived with his extended family in Kikwit, in a family compound consisting of huts made of wattle. Each day, G.M. commuted on a bicycle to his place of work in the little forest of Mbwambala.

Kikwit is situated on the banks of the Kwilu River, 250 miles east of Kinshasa, the capital of Congo. Kikwit stands on a rolling, grassy plateau that is dissected by streams the color of chocolate milk. The streams meander through valleys filled with gallery forest, narrow, snakelike stands of trees nestled along the streams. Most of the plateau had once been covered with tropical rain forest, but 90 percent of it had been cut down in recent decades.

Nobody had a clear idea of how many people lived in Kikwit. Some experts felt that the city had a population of around 150,000, while others had a feeling that the city might contain closer to half a million people. Kikwit had grown into a sprawling agglomeration of houses made of wattle and cinder block, with roofs made of grass or sheets of metal. The city was a transportation center of a sort. Overland trucks passed through the city, moving along the Trans-Africa Highway, a system of dirt roads that crosses Africa from the Atlantic Ocean to the Indian Ocean. This is the same system of roads along which the human immunodeficiency virus, HIV, seems to have moved across Africa after its trans-species jumps from unidentified animal hosts—most likely monkeys and chimpanzees—into the human species.

Congo had been ruled for many years by the dictator Mobutu Sese Seko, who’d maintained control using a corrupt, chaotic army. Many things that had once worked reasonably well in Congo now did not. At one time, it had been possible to drive an automobile from Kikwit to Kinshasa in just four hours over a paved road. Now the drive to the capital lasted anywhere from twelve hours to several days, when the road was passable. It had developed ruts up to ten feet deep.

Kikwit had no running water, no sewage system, no telephone network, no newspaper, and no radio station. At night, the city went dark; there was very little electricity. The city’s main hospital, Kikwit General Hospital, had a diesel generator. It also had an X-ray machine, but the hospital didn’t have running water or toilets. It didn’t even have bed-pans: a family member would provide a clay jar to collect the patient’s body waste. Many people who lived in Kikwit commuted by foot or bicycle to fields of cassava and maize outside the city. The people practiced slash-and-burn agriculture, moving their crops from place to place. The abandoned fields grew up in Christmas bush, an invading shrub from Florida and Central America. People also hunted small animals and gathered wood in the remaining patches of forest.

Just after dawn one day around Christmas 1994, G.M. got on his bicycle and pedaled through the city and down to the Kwilu River, and he crossed it on a bridge. He turned right and followed the river upstream through a valley. It was the rainy season. The weather was hot and wet, and the road was muddy; he threaded his way around puddles. After five miles he parked his bicycle, leaning it against a hollow stump near the road. Then he walked away from the road and away from the river, going uphill toward the east, following a footpath that went through thickets of Christmas bush and through fields of maize and cassava. He crossed a low ridge. The path descended. In about a mile, he came to a chocolate-colored stream. It wound among low hills through the forest of Mbwambala.

Mbwambala was a type of natural habitat that biologists call an ecotone. An ecotone is a transitional zone where two different ecosystems touch and mix. One sort of ecotone, for example, is the dividing line between wild forest and cleared agricultural land. Another ecotone is the meeting of sea with land, along a seashore. Ecotones are often richer in biodiversity. Living things find it easier to survive along edges, margins, boundaries, where different communities come together and mix, and where opportunities for feeding abound. Birds often congregate along ecotones—birds flock and feed along the edges of woods and along shorelines.

Mbwambala was a little ecotone, a narrow stretch of forest in the cleared country, running for a bit more than two miles along the stream. It contained groves of African corkwood trees. They had sprung up rapidly after the old, tall, primeval trees of Mbwambala had mostly been cut down. He walked along the stream, making his way under nightshade bushes the size of rhododendrons. There were small pigeonwood trees growing by the stream. Here and there, a few old forest trees remained—pale Tola trees and heavy, valuable Bomanga trees. These trees were 150 feet tall and maybe a century or two old. They were the remnants of a tropical forest canopy. Their crowns waved and flickered in the sunlight. In their tops lived bats, birds, insects, mites of the canopy—creatures that probably rarely came to the ground, if ever.

G.M.’s main profession was that of charcoalmaker. For years he had been cutting down trees in Mbwambala with an ax. He felled the trees and hacked up their branches and limbs and trunks into pieces, and made charcoal from them. The way he made charcoal was to dig a large pit, five feet deep, and fill it with pieces of wood. He set the wood on fire, then covered the burning wood in the pit with a layer of earth. The wood turned slowly into charcoal under the layer of earth.

Most cooking in Africa is done with charcoal. G.M. sold his charcoal to city people. That day, G.M. had just finished a session of charcoalmaking. He had recently removed a load of charcoal from his pit, and he now wanted to refill the pit. He spent the morning chopping down trees, lopping off their limbs, and moving the pieces of wood closer to his fire pit, in order to refill it with fresh wood.

What lived in the crowns of the trees he was chopping down no one really knows. Roughly half of all the species on earth are thought to live only in forest canopies. No one can say how many species exist on earth. Many biologists believe that most species on earth have not yet been identified and named. Most of these unnamed, undiscovered species (or life-forms) are viruses and bacteria. There are also thought to be many, many arthropods that have never been discovered. An arthropod is a small animal with an exoskeleton and jointed appendages—for example, an insect, a spider, or a shrimp.

HALF A YEAR LATER, when the disease hunters finally explored Mbwambala, they found a small, narrow hole that G.M. had dug during one of the last days of his life. The hole went down two feet among the roots of a tree. They wondered if he had dug up something in the hole and had eaten it. It might have been a tuber or a burrowing rodent with a nest of babies, or perhaps he had found a snake or some edible grubs there. Caterpillars are also a favorite food in Congo, especially a particular caterpillar that has a hard, shiny black head and a soft body and can grow up to five inches long. People in Congo roast it over a charcoal fire. Perhaps G.M. found some unusual wild caterpillars in the leaves of a tree he had cut down and ate them. He kept a few snares and traps in Mbwambala, for catching small animals, which he brought home to his family to eat. Perhaps he’d visited his snares, perhaps not; no one knows. Perhaps an animal bit him while he was taking it out of one of his snares; no one knows. The animals that turned up in his snares were mostly wild rats, including the giant African rat, which can be the size of a small dog. Some local people claimed, afterward, that G.M. had stolen an animal from someone else’s snare.

Later in the day, he headed farther up the creek, deeper into Mbwambala. There, he visited a couple of maize fields he was tending. He had carved these fields out of the forest. During the heat of the day, he took a nap under a small shelter in one of his fields. Perhaps he was bitten by a spider or insect while he slept in the shelter. He returned to the city at dark. He had traveled twenty miles that day.

He would never visit the place again. Over the next few days, he began to feel unwell. He stayed home at his family compound in Kikwit. He ran a high fever; his eyes turned bright red. He got the hiccups, and they simply wouldn’t stop. His face assumed a masklike appearance. He began defecating blood into his bed. His family took him to the Kikwit General Hospital, in the center of the city, where he died on January 13, of what people in the city would later call la diarrhée rouge, the red diarrhea.

2. Maternity Ward

BY LATE JANUARY, three members of G.M.’s family had died of la diarrhée rouge. Ten more members of his extended family, who lived in Kikwit and in surrounding villages, also came down with it. Some of them got endless hiccups, and all of them died. They, in turn, infected more people, and they all died.

Then it got into the Kikwit Maternity Hospital. This was a small collection of buildings in the south-central part of the city where pregnant mothers went to have their babies delivered. When a pregnant woman came down with it, the first sign was brilliant red eyes. The eyelids would eventually ooze blood, and the blood would stand on the edges of the eyelid in beaded-up droplets. The urine turned red—the kidneys were hemorrhaging; then the kidneys failed, and the person stopped urinating. The infected women in the maternity ward developed a masklike facial expression, and they became disoriented. Some had seizures. The disease was attacking the central nervous system. Some of them abruptly went blind. The skin became covered with a rash, a sea of tiny bumps, like goose bumps. The patients suffered from disseminated intravascular coagulation (DIC), in which the blood formed tiny clots throughout the body. At the same time, some of the patients were having hemorrhages, including bloody noses; in many patients, the stomach became distended and they began vomiting blood.

The illness invariably caused pregnant mothers to abort the children they were carrying; the fetus or baby was always either born dead or died shortly after birth. None of the babies of ill mothers survived. During the delivery, the women experienced profuse, body-draining hemorrhages from the birth canal, and they died of hypovolemic shock. This is the shock that occurs when much of the blood has been drained from the body.

The doctors and nursing staff who worked in Kikwit Maternity Hospital did the best they could, but the hospital suffered from a shortage of basic medical supplies, such as rubber gloves. The doctors thought that they were dealing with an outbreak of dysentery.

On April 10, a medical technician who had been working with dying mothers at Kikwit Maternity Hospital came down with severe stomach pains. I will refer to him as the Maternity Technician. He went across town to the Kikwit General Hospital to get himself examined and treated. A doctor there suspected that the Maternity Technician had typhoid fever with peritonitis—a bacterial infection of the abdomen that is fatal if it isn’t treated immediately. The doctors at Kikwit General Hospital put the Maternity Technician into surgery.

A group of Italian nuns worked in the hospital as nursing sisters. They were known as the Little Sisters of the Poor, and they came from a convent in Bergamo, Italy.

One of the nuns, Sister Floralba Rondi, assisted two surgeons and a nursing team in the operating room on the day they operated on the Maternity Technician. The lead surgeon made a vertical cut down the center of the technician’s abdomen, opened him up, and looked into his abdominal cavity. They were expecting to see pus. Pus occurs with a bacterial infection. There was no pus; there were no bacteria. (Viruses are not bacteria.) The surgical the team took out the man’s appendix.

The next day, however, the Maternity Technician grew worse. His abdomen became very swollen and distended. Wanting to see what was causing the distension, the doctors inserted a hypodermic syringe into his abdomen and extracted a sample. The syringe filled up with blood. The blood had a runny, homogenized appearance. It wouldn’t coagulate.

The doctors brought him back into the operating room and opened him up through the same incision as before, in an effort to find the source of his bleeding and stop it. They couldn’t find any source for the bleeding. The blood seemed to be coming directly out of his organs, as if from a squeezed sponge. They sewed him back up. By the time the surgical team had finished the surgery, the team members were probably smeared with the Maternity Technician’s blood and probably had it all over their hands. Some or all of the team members performed the surgery without gloves, with bare hands.

Two days later, the Maternity Technician died.

In the next ten days or so, nearly every member of the team that had operated on the Maternity Technician also died, including Sister Floralba and two surgeons. Other medical staff who had been caring for the Maternity Technician, including Sister Dinarosa, died as well. At this point, it was clear that there was a dangerous disease loose in the hospital. The doctors wanted to get the word out and get help. There was no telephone at the hospital, but the hospital had a communication radio. Every evening at the same time, the surviving nuns sent out a radio bulletin, reporting on the events of the day, the deaths that had occurred. This message was relayed by fax every day to the convent of the Little Sisters of the Poor, in Bergamo, Italy. The nuns in Bergamo were becoming increasingly alarmed about the deaths of their sisters in Kikwit.

As the news got out that the disease killed practically everyone who got it, the city of Kikwit went into a panic. Almost all of the patients who were in Kikwit General Hospital fled back to their homes, fearing the disease in the hospital. Some of them went to the villages surrounding Kikwit. Because of the bleeding and the high rate of mortality, the doctors began to believe that they were dealing with Ebola.

They set up an isolation ward in Pavilion Three of the Kikwit General Hospital. They brought in thirty patients who were suffering from the red diarrhea and placed them in the beds. The mattresses soon became soaked with blood and filth, and the floors became slippery with blood.

One of the physicians, Dr. Mpia A. Bwaka, volunteered to stay in Pavilion Three with the patients. By this time, it was fairly obvious to Dr. Bwaka that this decision meant that he would probably die. He was helped by three male nurses who also volunteered to stay with the patients, even though they knew that they would probably get the disease and die. The nurses’ names have not been recorded in the medical literature; they were local men from Kikwit who were earning next to nothing for their work. Dr. Bwaka wasn’t getting paid, either. The hospital’s staff had not received their salaries in several months; economic conditions in Congo were very bad.

Dr. Bwaka and the three men gathered up the hospital’s small supply of rubber gloves and took them into Pavilion Three. They wore the gloves sparingly, washed them, and reused them. They wore cloth surgical gowns and handmade masks woven locally from cotton. They slept in the pavilion with their patients. As the patients died, the corpses were left in the beds or were placed on the floor, to make room for more people being brought into Pavilion Three. By now, hundreds of people in Kikwit and the surrounding towns were dying of it. It had all come from one man who had gone into the forest in Mbwambala and come into contact with some wild creature there.

3. Identification

IN PAVILION THREE of the Kikwit General Hospital, Dr. Mpia Bwaka collected samples of blood from fourteen of his patients. Somebody drove the samples over the terrible road to Kinshasa. From there, the blood samples were flown to a laboratory in Belgium. The Belgian scientists, fearing that the blood might be dangerous, sent them along to the Centers for Disease Control and Prevention in Atlanta—the CDC. The fourteen tubes of blood from Pavilion Three ended up in the Biosafety Level 4 hot zone of the Special Pathogens Branch, where a researcher named Ali S. Khan, working along with several colleagues, identified Ebola virus in all fourteen of the test tubes. It was a new type of Ebola virus, and it would eventually be named Ebola Kikwit.

As it happened, just at that time, another new type of Ebola was causing an outbreak in Ivory Coast, in West Africa. This type of the virus would eventually be named Ebola Ivory Coast. Thus two outbreaks of different types of Ebola occurred almost simultaneously in different places, which deepened the mystery over the origin of Ebola. Why and how was Ebola emerging in different places? A medical team from the World Health Organization, in Geneva, was preparing to fly to Ivory Coast, in West Africa, to investigate.

The WHO Ebola Ivory Coast team was led by Bernard Le Guenno, a scientist from the Institut Pasteur in Paris, and by Pierre Rollin, a French virologist who was then stationed at the CDC in Atlanta. But with the large outbreak happening in Congo, which needed immediate attention, Bernard Le Guenno and Pierre Rollin were sent to Congo instead, where they joined a ten-member WHO team of doctors from France, Congo, the United States, and South Africa.

The Ivory Coast Ebola case had occurred about a month before G.M. got sick—he was the first person known to have Ebola Kikwit. In Ivory Coast, a woman scientist from Switzerland (whose name has never been publicly disclosed) was studying a troop of wild chimpanzees in Taï National Park. The Taï Forest was one of the last pristine rain forests in West Africa. The troop of chimpanzees became infected with a mysterious disease, and many of them died. The Swiss woman, extremely concerned about her chimps, dissected one of the dead animals, trying to find out what had killed it. Soon afterward, she developed a rash and became severely ill, and she began having hemorrhages. She developed the symptoms of Ebola virus.

For unknown reasons, Ebola had been getting into chimpanzees. Chimps and other great apes, such as bonobos and gorillas, are probably not natural hosts of Ebola virus. This is because Ebola makes the apes extremely sick—as sick as humans become with the virus. (The western gorilla is presently very threatened by Ebola virus, and many gorillas have died in Congo from outbreaks of Ebola among them. No one knows how the gorillas are getting Ebola, but some wildlife biologists fear that Ebola could help cause the western gorilla’s extinction.) The fact that Ebola is exceedingly lethal in monkeys and apes means that the natural host of Ebola is probably not a monkey or ape—those animals haven’t developed resistance to it. But somehow, the chimpanzees of the Taï Forest were coming into contact with Ebola’s host.

The Swiss woman was flown on a commercial airliner to Switzerland for treatment. Her doctors in Switzerland did not realize that she was infected with Ebola. They suspected that the illness was dengue hemorrhagic fever, a virus carried by mosquitoes. Nevertheless, she survived, and no one else in the hospital in Switzerland got sick.

The Taï chimps ate all sorts of things. They hunted colobus monkeys and ate them raw, tearing them apart, a bloody process. Possibly the chimps were catching Ebola from dead monkeys; the monkeys might have been catching Ebola from some other creature they were hunting.

There was another curious case of an Ebola-like illness at the same time. A twenty-one-year-old Swedish medical student who had been traveling in Kenya returned to Sweden. He had lived for a month in the town of Kitale, which is at the base of Mount Elgon, about twenty-five miles from Kitum Cave, a site that may be a hiding place of the type of Ebola called Marburg virus. The Marburg virus may not necessarily exist all the time inside Kitum Cave. It could just as easily live in a host that occasionally visits Kitum Cave. At any rate, the Swedish medical student didn’t visit the cave during his time near Mount Elgon. Five days after his flight arrived in Sweden, he became deathly ill, and he ended up in the University Hospital in Linköping—a world-class research hospital. He was showing all the signs of African hemorrhagic fever. He began to bleed out of the openings of his body.

A medical team at the Linköping hospital scrambled to save his life. A nurse was bending over his face when he suddenly vomited blood into the nurse’s eyes (she wasn’t wearing eye protection). In the ensuing flurry, two other members of the team accidentally stuck themselves with needles. These accidents with blood and needles did not happen because the medical workers at Linköping were incompetent; they were highly trained. The accidents happened because they rushed in to save a patient’s life, forgetful of their own safety. This is what Dr. Mpia Bwaka and his nursing team were doing at the Kikwit General Hospital. Unlike the Swedish team, however, the Congolese doctors had virtually no medical supplies, and were working in a run-down cauldron of a hospital that had been virtually abandoned by government authorities. Dr. Bwaka and his team were working literally up to their elbows in blood, black vomit, and excrement the color of beet soup. The team didn’t even have running water to rinse the floors of Pavilion Three.

In Linköping, Sweden, the ill Swedish student survived. A team from the United States Army Medical Research Institute of Infectious Diseases, or USAMRIID, at Fort Detrick, Maryland, flew into Sweden carrying biohazard space suits and other gear, to help investigate the case. The Army team discovered that fifty-five medical personnel at the Linköping hospital had been exposed to the patient’s blood and bodily fluids. They were all at risk of being infected with the unknown infectious agent. Almost unbelievably, no one became sick, including the nurse who had got a faceful of blood. The researchers were never able to identify an infectious agent in the student’s blood. It remained a case of “suspected Marburg virus.” Despite the happy outcome in Sweden—the student and everyone else survived the incident—it showed that the best hospitals and the best medical people are still vulnerable in the face of an unidentified infectious agent that finds its way into the health-care system.

4. Ebola Kiss

WHILE EBOLA was breaking out in Kikwit, I spoke with a doctor named William T. Close, who had lived in Congo (then Zaire) for sixteen years. When he was in Zaire, Bill Close rebuilt and ran the Mama Yemo General Hospital, a two-thousand-bed facility in the capital. When Ebola broke out for the first time, in 1976, Close went to Zaire and helped coordinate the medical effort to deal with the virus, and advised the Zairian government. Years later, during the Ebola Kikwit outbreak, he acted as a liaison between Congolese government officials and doctors from the CDC in Atlanta.

“In 1976, when Ebola broke out in Yambuku that first time, there was a nun, Sister Beata, who died of Ebola,” Close recalled. “There was a priest, Father Germain Lootens, who gave her the last rites as she died. She had a terrible fever, sweat was pouring down her face, and bloodstained tears were running down her face. Father Lootens took out his handkerchief and wiped the sweat from her forehead and the bloody tears from her face. Then, unthinkingly, he took the tearstained handkerchief and wiped the tears from his own face with it—he had been crying, too. A week later, he came down with Ebola, and a week after that he was dead.”

Now, Close had been hearing reports that some members of the medical staff of Kikwit General Hospital—Dr. Bwaka and his nurses—had continued to care for Ebola patients despite the grave risks to themselves. “Those hospital staff people have gone into that hospital to work knowing that they may die,” Close said. And the doctors and nurses in Kikwit were working without basic medical supplies. “The greatest need in Kikwit right now is for rubber aprons to protect the doctors and nurses, because the blood and vomit is soaking through their operating gowns,” he said. “This is a huge, lethal African hemorrhagic virus. We all sort of feel that Ebola comes out of its hiding place when something occasionally alters the very delicate balance of the ecosystems, in a tropical region where things grow as they would in a petri dish. But if there are lessons to be learned here, they are human lessons. This is about people doing their duty. It’s about doctors doing what has to be done, right now, without a whole lot of heroics. Have you ever been petrified with fear? Real fear? Possessed by naked fear, where you have no hope of control over your fate? If you’re a medical worker, when the die is cast, the fear goes away, and you do what you have to do—you get to work. That’s what’s happening with the medical people in that hospital right now. There are things happening in Kikwit…” He paused. “Magnificent human things…. How can I explain this? There was another incident in 1976, also in Yambuku. One of the doctors—he was a Belgian named Jean-François Ruppol—delivered a baby in the middle of it all.” Ebola has a profound effect on pregnant women: they hemorrhage profusely and abort the fetus, which itself is infected with Ebola. “There were people dying of Ebola all around in that room in the hospital, and there was a woman in childbirth. She was Dr. Ruppol’s patient, and her baby was his patient, too. The baby was stuck—too big for the birth canal.” The woman had a high fever, she was terribly ill, but her baby had to be delivered, even if it was infected with Ebola. “So he performed the Zarate procedure on her,” Close said.

“What’s that?” I asked.

“The Zarate procedure? It’s a simple and rather crude but very effective way of enlarging the outlet to remove the baby. With a knife, you split the pubic symphysis.”

“The what?”

“The front of the pelvis. The pelvic bones,” he said. It’s a hard, bony spot, and you can feel it, just above the pubic area, he said. “You split the bones there. You press a scalpel through cartilage. The bones go pop and the pelvis springs open, and you pull the baby out. The hospital had run out of anesthetics. So he did the Zarate procedure on the woman without giving her an anesthetic.”

“My God.”

“She was conscious. By the time he got the baby out, the baby had stopped breathing. The baby was in breathing arrest and drenched with the woman’s blood. He put the baby’s mouth to his mouth and gave the baby mouth-to-mouth resuscitation. The baby started to breathe. He pulled away, and his mouth and face were smeared with blood. There was a nurse standing by. When she saw his face she said, ‘Doctor, do you realize what you’ve done?’

“‘I do now,’ he said.”

5. Seeking the Ghost

WHEN THE WHO TEAM ARRIVED in Kikwit, they found Dr. Mpia Bwaka working alone in Pavilion Three with only two nurses—the third nurse had died of Ebola a few days earlier. Dr. Bwaka seemed to be all right. The WHO team had brought medical supplies, including jugs of bleach. They washed the ward with the bleach, rinsing the blood and feces off the floor. The team members put on double rubber gloves, waterproof gowns, masks, and goggles, and distributed the same equipment to Dr. Bwaka and his nursing staff. They wrapped the mattresses (which were blood-soaked) in plastic covers. Afterward, Ebola patients were placed directly on the plastic, without sheets. A Belgian team from Doctors Without Borders arrived a few days later, and put up white Tyvek sheets around Pavilion Three, as a sort of crude barrier to keep the virus inside the pavilion; the Belgian team also brought water for the hospital. Dr. Bwaka continued to work in the Ebola ward. It was so hot that the goggles fogged up, so the medical workers often didn’t wear them. One day, a nurse forgot himself momentarily and wiped his eyelid with his gloved fingertip, which was contaminated with Ebola blood. He died of Ebola.

But by the time the teams arrived in Kikwit, the outbreak was fading away. What really ended it was the fact that the virus had killed a third of the doctors in the city. Once the medical system collapsed, people didn’t go to the hospitals where the virus had spread. The outbreak burned itself out. Dr. Mpia Bwaka survived.

IN THE FOLLOWING MONTHS, a team of epidemiologists and zoologists led by Herwig Leirs, an ecologist at the Danish Pest Infestation Laboratory in Lyngby, Denmark, fanned out into the countryside around Kikwit and began trapping animals and birds and testing their blood. They were trying to find a species of animal that was either infected with Ebola or had antibodies to Ebola in its bloodstream, which would suggest that the animal was a natural carrier of the virus. They set out traplines and mist nets all through the forest of Mbwambala, and in other places in the countryside around the city. In the end, they collected slightly more than three thousand specimens. Most of them were mammals. About ten percent of the specimens were birds, and a few of them were reptiles and amphibians. Most of the mammals were rodents, and there were a number of bats. But they also collected wild African cats, as well as wild red pigs, pangolins, and elephant shrews. Not one of the specimens turned up positive for Ebola virus. Not one.

The Danish team didn’t look at any insects. Insect biodiversity in tropical Africa is enormous and unfathomed—many species of insects in Congo have never been identified or given names. A collecting team led by Paul Reiter of the CDC went around Kikwit and the countryside and collected thirty-five thousand arthopods—insects, ticks, sand flies, fleas, lice. They collected many bedbugs from around the city. For some reason, they didn’t catch any spiders or scorpions. They also didn’t report collecting any mites. (Mites are very small arthropods that are very difficult to see and collect.) Mites can live in hair follicles or on the skin of an animal or person, as well as in soil. The CDC arthropod team didn’t find any trace of Ebola in any of the thirty-five thousand specimens. No Ebola in a single bug.

It left the mystery unsolved. In what creature does Ebola make its everyday home? One interesting question about Ebola is this: Why aren’t humans infected more often with Ebola? Why are the outbreaks actually quite rare? If Ebola lives in some common animal or insect, then people should become infected more frequently. Possibly Ebola lives in primeval rain-forest canopies, in some creature that exists high above the ground in the remains of an ancient forest ecosystem. When a forest is disturbed—when trees are chopped down—people come in contact with the canopy and all that lives there. Perhaps the first man with Ebola in Kikwit, G.M., cut a tree down, then touched or ate a bat, bird, or insect that lived only in the tops of trees. Or perhaps he got Ebola from something that had lived underground, something he found in the small hole he dug that day in Mbwambala. He was dead, and many members of his family—who might otherwise have been able to recall details of his activities during the days when he became infected—were dead, too. Ebola kills the witnesses to its appearance. There were hints that some type of bat might be the natural host of Ebola. In laboratory tests, Ebola virus has been able to infect certain kinds of bats without making them sick. The bat’s immune system is resistant to Ebola, which suggests bats may be carriers of the virus. Even so, no wild bats have ever been found with Ebola in them.

Bats have very unusual wingless parasitic flies that live on them, sucking their blood. These bloodsucking bat flies, called strebelid flies, crawl from bat to bat while the bats are hanging in roosts. The flies might transmit Ebola among the bats. Does Ebola live in wingless flies crawling on bats? Nobody knows.

This is a story with no end. Recently, I called Dr. William Close, to see how he was doing. He lives in Big Piney, Wyoming.

“That Belgian doctor,” I said. “The one who got the Ebola-infected blood all over his face? How long did he survive?”

Close began chuckling. “More than thirty years, so far. I just talked with him yesterday. Jean-François Ruppol. He’s a great friend of mine. He lives in Belgium now.”

I could hardly believe it. How could anyone survive an Ebola exposure like that?

Not long afterward, I received a series of pleasant e-mails from Dr. Jean-François Ruppol. He had written down, in French, some of his recollections of the first Ebola outbreak, in Yambuku, near the Ebola River, Congo, in 1976. Ruppol went to Yambuku three times during the outbreak, seeking to understand the virus and get it under control. (At the time, Ebola virus did not yet have a name.) Here, in Ruppol’s words, is what happened:

Ma première nuit à Yambuku fut calme…. My first night in Yambuku was calm, but around five o’clock in the morning, a nursing sister woke me, banging on the door of the room I was occupying. A woman had just been brought in who had been in labor for a full day, and her situation didn’t look good. I have to admit that I was a little nervous. For one thing, I didn’t want to go into the hospital or the maternity ward, where there had been numerous sick patients and where the virus might still be present in patches of blood and soiled sponges that were scattered all about. For another thing, practically all of the male and female nurses had died, and the survivors had fled. Was the woman they had just brought in contaminated?

At this point, I asked a nun if they could put a kitchen table on the building’s porch. We put the pregnant woman on the table, after we had donned protective gear (gown, cap, mask, gloves, etc.). I wanted to take all the necessary precautions, the same ones I had ordered others to use during this epidemic.

In the course of my examination, I came to the following conclusions:

• The woman was at the end of her rope.

• The fetus was presenting in a dangerous way. If I remember correctly, the fetus was stuck sideways, making birth impossible.

• The fetus was in extremis.

We had to act quickly. But a caesarean was impossible because of the dangers in the operating room, the blood and foul sponges, and because of the absence of qualified personnel. Therefore I decided to utilize a technique that I had occasionally practiced in Kimpangu, the symphysisiotomy [the Zarate procedure]. It consisted of cutting the cartilage at the pubic symphysis, and then spreading the legs to open the pelvis and favor the passage of the fetus.

Getting the help of two people to hold the mother’s knees and legs, I performed the Zarate procedure under a local anesthetic, and I reached in and turned the fetus around inside her, in order to deliver it bottom-first.

Illuminated by flashlights and an electric light from a generator, the maneuver went well, but once the baby was delivered and the umbilical cord cut, the baby would not breathe despite various attempts to wake it up. Then, pushed by habit (or instinct, perhaps?), I took down my mask and practiced gentle mouth-to-mouth resuscitation. At that very moment I got a terrible shock: I realized that if the woman was infected with the virus, then I had just condemned myself to death. This was because we knew the virus was transmitted in all the secretions and fluids of the body. Even so, the child was revived and the mother seemed to be doing all right. It’s hardly necessary to add that I spent the next forty-eight hours keeping a very close watch on the health of the mother and baby. Oof! They weren’t contaminated, and I was alive. This was the only time in my medical career when I was not just afraid, but felt and lived real terror….

Ruppol had lost his sense of self-protection during the emergency, but had gotten lucky. The mother hadn’t had Ebola.

Close thought it was just typical of the way doctors can forget themselves when a patient is in trouble. It didn’t give him any confidence, though, that the doctors had the situation with emerging viruses and microbes under control. “In the battle between the doctors and the bugs,” he remarked, “in the long run, I’d put my money on the bugs.”