The End of October

I

Kongoli

1 Geneva

In a large auditorium in Geneva, a parliament of health officials gathered for the final afternoon session on emergency infectious diseases. The audience was restless, worn out by the day-long meetings and worried about catching their flights. The terrorist attack in Rome had everyone on edge.

“An unusual cluster of adolescent fatalities in a refugee camp in Indonesia,” the next-to-last speaker of the conference was saying. Hans Somebody. Dutch. Tall, arrogant, well fed. An untrimmed fringe of gray-blond hair spilled over his collar, the lint on his shoulders sparkling in the projected light of the PowerPoint.

A map of Indonesia flashed on the screen. “Forty-seven death certificates were issued in the first week of March at the Kongoli Number Two Camp in West Java.” Hans indicated the spot with his laser pointer, followed by slides of destitute refugees in horrible squalor. The world was awash in displaced people, millions pressed into hastily assembled camps and fenced off like prisoners, with inadequate rations and scarce medical facilities. Nothing surprising about an epidemic spilling out of such places. Cholera, diphtheria, dengue—the tropics were always cooking up something.

“High fever, bloody discharges, rapid transmission, extreme lethality. But what really distinguishes this cluster,” Hans said, as he posted a graph, “is the median age of the victims. Usually, infections randomly span the generations, but here the fatalities spike in the age group expected to be the most vigorous portion of the population.”

In the large auditorium in Geneva, the parliament of health officials leaned forward to study the curious slide. Most mortal diseases kill off the very young and the very old, but instead of the usual U-shaped graph, this one resembled a crude W, with an average age of death of twenty-nine. “Based on sketchy reports from the initial outbreak, we estimate the overall lethality at 70 percent,” Hans said.

“Pediatric or natal  .  .  .  ?” Maria Savona, director of epidemiology at the World Health Organization, interrupted the puzzled silence.

“Largely accounted for in the reported cohort,” Hans replied.

“Possible sexual transmission?” a Japanese doctor asked. “Unlikely,” said Hans. He was enjoying himself. Now his face drifted into the projection, casting a bulky shadow over the next slide. “Reportable deaths stay consistent for the following weeks, but the overall total drops significantly.”

“A one-time event, in that case,” the Japanese woman concluded.

“With forty-seven bodies?” Hans said. “Quite an orgy!”

The Japanese doctor blushed and covered her mouth as she giggled. “Okay, Hans, you’ve kept us guessing long enough,” Maria said impatiently.

Hans looked around the room triumphantly. “Shigella,” he said, to groans of disbelief. “You would have got it but for the inverted mortality vector. That puzzled us as well. This is a common bacteria in poorer countries, the cause of innumerable cases of food poisoning. We queried the health authorities in Jakarta, and they concluded that, in a starving environment, the only people robust enough to seize the limited food resources are the young. In this case, strength proved to be their undoing. Our team deduced that the probable source of the pathogen was raw milk. We offer this as a cautionary tale about how demographic stereotypes can blind us to facts that would otherwise be obvious.”

Hans stepped down to perfunctory applause as Maria called the last presenter to the podium. “Campylobacter in Wisconsin—” the man began.

Suddenly, a commanding voice interrupted. “A raging hemorrhagic fever kills forty-seven people in a week and disappears without a trace?”

Two hundred heads turned to locate the source of that booming baritone. From the voice, you would have thought Henry Parsons was a big man. No. He was short and slight, bent by a childhood case of rickets that left him slightly deformed. His facial features and professorial voice seemed peculiarly outsized in such a modest figure, but he carried himself with the weight of a man who understood his value, despite his diminished appearance. Those who knew his legend spoke of him with a kind of amused awe, calling him Herr Doktor behind his back, or “the little martinet.” He was capable of reducing interns to tears if they failed to prepare a sample correctly or missed a symptom that was, in fact, meaningful only to him, but it was Henry Parsons who led an international team in the Ebola virus disease outbreak in West Africa in 2014. He tracked down the first documented patient of the disease—the so-called index case—an eighteen-month-old boy from Guinea who had been infected by fruit bats. There were many such stories about him, and many more that could have been told, had he sought the credit. In the neverending war on emerging diseases, Henry Parsons was not a small man; he was a giant.

Hans Somebody squinted and located Henry in the gloom of the upper tiers. “Not so unusual, Dr. Parsons, if you consider the environmental causation.”

“You used the word ‘transmission.’ ”

Hans smiled, happy to resume the game. “The Indonesian authorities at first suspected a viral agent.”

“What changed their minds?” Henry asked.

Maria had become intrigued. “You are thinking Ebola?”

“In which case we’d see likely migration to urban centers,” Hans said. “Not shown. All it took was to eliminate the source of contamination and the infection disappeared.”

“Did you actually go to the camp yourself?” Henry asked. “Take samples?”

“The Indonesian authorities have been fully cooperative,” Hans said dismissively. “There is a team from Médecins Sans Frontières in place now, and we will receive confirmation shortly. Don’t expect surprises.”

Hans waited a moment, but Henry sat back, thoughtfully tapping a finger on his lips. The next presenter resumed. “A slaughterhouse in Milwaukee,” he said, as a few conferees with an eye on the time ducked toward the exits. There was bound to be increased security at the airport.

“I hate when you do that,” Maria said, when they got to her office. It was glassy and stylish, with a fine view of Mont Blanc. A flock of storks, having hurdled the alpine barrier, circled for a landing beside Lake Geneva, their first stop on the spring migration from the Nile Valley.

“Do what?”

Maria leaned back and tapped her finger on her lips, imitating Henry’s gesture.

“Is that a habit of mine?” he asked, leaning his cane against her desk.

“When I see you do it, I know I should be worried. What makes you doubt Hans’s study?”

“Acute hemorrhagic fever. Very likely viral. Weird mortality distribution, totally inappropriate for shigella. And why did it suddenly—”

“Just stop? I don’t know, Henry, you tell me. Indonesia again?”

“They hid the ball before.”

“It doesn’t look like another meningitis outbreak.”

“Certainly not.” Despite himself, Henry involuntarily began tapping his lips again. Maria waited. “I shouldn’t tell you what to do,” he finally said. “Maybe Hans is right.”

“But . . . ?”

“The lethality. Stunning. The downside if he’s wrong.”

Maria went to the window. Clouds were settling in, masking the majestic peak. She was about to speak when Henry interrupted her thought. “I’ve got to go.”

“That’s exactly what I was thinking.”

“I mean home.”

Maria nodded in that way that meant she had heard him, but the worried expression in her Italian eyes sent a different message. “Give me two days. I know how much I’m asking. I should send a whole team, but I don’t have anybody I can trust. Hans says MSF is there, so they can help. Just get slides and samples. In and out and on your way back to Atlanta.”

“Maria . . .”

“Please, Henry.”

In the manner of friends who have known each other a long time, Henry saw a flash of the worried young epidemiologist studying the African swine fever outbreak in Haiti. Maria had been part of the team that advocated the eradication of the indigenous pig that carried the disease. Nearly every family in Haiti kept pigs; in addition to being a major source of food, they functioned as currency, a bank for the peasantry. Within a year, thanks to the efforts of the international community and the dictator “Baby Doc” Duvalier, the entire population of Creole pigs was extinct, a great success, almost unprecedented. The eradication stopped an incurable disease. But the peasants, already poor, were reduced to famine. The corrupt elite appropriated most of the replacement pigs the Americans provided, which were in any case too delicate for the environment and too expensive to feed. With no other resources, people turned to making charcoal, which denuded the forests. Haiti never recovered. It’s debatable whether the hogs should have been slaughtered in the first place. We were such confident idealists back then, Henry thought.

“Two days, maximum,” he said. “I promised Jill I’d be home for Teddy’s birthday.”

“I’ll have Rinaldo book you on the red-eye to Jakarta.” Maria assured him that she would call the Centers for Disease Control and Prevention, in Atlanta, where Henry was deputy director for infectious diseases, and beg forgiveness; it was an emergency request on her part.

“By the way,” he said as he was leaving, “any word from Rome? Your family is safe?”

“We don’t know,” Maria said despairingly.