One Phone Call
Dr. Joel Breman, an epidemic intelligence officer, had just left the frigid air of a Michigan autopsy room in October 1976 when the phone rang. It was Lyle Conrad, supervisor of CDC’s field officers. “There’s a very unusual outbreak in Africa,” the director said. “We want to you to go there.”
Less than eight months earlier, Breman thought he had left West Africa after spending almost a decade fighting smallpox, measles, and other diseases in Guinea, Burkina Faso and elsewhere in West Africa accompanied by his wife, a nurse. With two small kids, the couple had decided to settle in Michigan for two years, where they could work at a quiet state outpost of the CDC and let their children grow up in the suburbs. But with one phone call, Breman knew he had to go back. He was well suited for the task: he spoke fluent French, knew many greetings in local languages, and had a disposition that made people feel at ease.
“Just for a few days,” Conrad urged. “Find out what’s going on and then come back, we’ll take care of the rest.”
An unusually lethal hemorrhagic fever was sweeping through the region. The virus—which caused fever, headache, vomiting, diarrhea, and rash—resembled malaria, typhoid, Lassa fever, and influenza. Its mortality rate did not. “All the villages are infected,” the director warned Breman. “Virtually all those who have gotten it have died.” So far, the infection was confined to Zaire (now known as the Democratic Republic of the Congo), by chance a place Breman had been earlier in the year as a member of a WHO international team to certify Central Africa smallpox-free.
In the days leading up to his departure for Africa, the California native searched for clues that might unlock the identity of the mystery virus. He spent days and nights pouring over scientific journals. “It was so lethal and dramatic,” he says. “There was no disease I knew that could be so deadly.” Breman also reached out to others for help. Bob Kaiser, chief of tropical diseases at the CDC, was stumped by the descriptions of the fever. So was Thomas Monath, the doctor who had just unraveled the natural history of Lassa fever. Breman kept calling doctors and academics, but there were no answers to be found.
The reality of Breman’s situation was starting to sink in. He was flying to a foreign country to visit gravely ill patients suffering from a disease he could no more diagnose than treat. In some ways, it was an impossible mission. “I had a brief conversation with my wife and two small children,” he says. “We didn’t know what was going to happen. It was extremely difficult.” Breman kept repeating the phrase, “just a few days.” He packed only two pairs of pants, three shirts, and one toothbrush, then set out for Africa with Karl Johnson.
Journey to Zaire
The head of the CDC’s Special Pathogens lab, a brilliant virologist by the name of Karl Johnson, had been chosen as Breman’s companion by the CDC director. Together, they’d be the first Americans on an international commission, formed to investigate the hemorrhagic fever. On departure, Johnson informed Breman that his lab had just discovered the cause of the outbreak—a new virus—and showed him a picture of the spaghetti-shaped microbe. It was crucial news, but only one piece of the puzzle. A magnified image of a microbe didn’t tell the story. “We had to find out what it caused … how it manifested,” says Breman. “Then our work began.”
When they also learned just before departure that a concurrent outbreak had just begun in south Sudan—this one in an isolated area, virtually impossible to reach—their bewilderment deepened. Was it the same virus? Were the outbreaks related? To break up the trip to Zaire, the two stopped in Geneva to meet with leaders at the World Health Organization.
Unable to sleep on the more than 12-hour flight from Geneva to Zaire, Breman and Johnson ran through various clinical and epidemiologic scenarios. Sitting next to the doctors, eavesdropping on their conversation, was an American surgeon named William T. Close—whose daughter, Glenn, was a 29-year-old rising star in Hollywood.
Bill Close, as his friends called him, was the personal physician to President Mobutu Sese Seko of Zaire. President Mobutu was rumored to have recently fled to France with his family to protect them from the virus. Close decided to return to Africa from his home in the U.S. He knew the virus was spreading, but he hadn’t grasped the gravity of the situation until overhearing the CDC scientists.
Close was one of the most authoritative people in Zaire. Along with his post as Mobutu’s personal physician, he was director of the biggest and best hospital in the country; it was named “Mama Yemo” after the President’s mother. This post granted him unrestricted access to government medical and laboratory supplies. Along with colleagues from Zaire and other countries, Breman and Johnson had the brainpower to fight the virus; Close had the resources they needed to do it. “If we hadn’t met [Bill], if he hadn’t welcomed us with open arms, I don’t know how it would have gone,” says Breman.
By the time the plane landed in Kinshasa, Zaire’s capital city, the men had a game plan. It was late October, six weeks after the initial outbreak, and the virus was rumored to be spreading like wildfire. Once they arrived in Zaire, Breman was appointed the commission’s Chief of Surveillance, Epidemiology, and Control; Johnson was named Scientific Director. Containment was top priority. Close sent medical scrubs from his storehouse, ordered the chief electrician to wire the Yambuku hospital, and galvanized the country’s reluctant air force to offer support. When the Minister of Health asked five commission members to go to the site of infection hours after the group arrived, Close ordered a large military plane to fly them there. Breman was among those chosen for the flight. Their mission was four-fold: map the extent of the outbreak, track down active cases, find possible survivors, and assess needs for clinical care and further research and control. The five men, their Land Rover, and their supplies were loaded into the gigantic military aircraft. As the pilots prepared for takeoff, Breman sensed their unease. “They were not happy to take us,” he says. The village and surrounding area they were traveling to was quarantined, and had been for weeks. It was here, a small village in the Mongala District of northern Zaire, where it all began. Yambuku.
Breman peered out at the huge Congo River system as the flight took off. Small slips of road peaked out from under the dense canopy, exposing tiny villages scattered throughout the jungle. Below, the thick marshland and dim lights created a scene that Breman describes as “Joseph Conrad territory.” “You’re flying into the unknown,” he says. “Pretty terrifying.” Minutes after landing in Bumba and unloading the cargo, the pilots and their plane vanished. “You realize, they’re gone and we are here. We’re totally isolated across the river.” The hunt for the virus had begun.
Not far from the drop-off point, the team ran into their first roadblock. The villagers, who had been under quarantine for weeks, had been told by their governor not to let strangers in—under any conditions. With man-made barriers they fought to keep the doctors out. “People were panicking, they didn’t know what was going on,” Breman remembers. “They thought we were bringing the disease.”
After making it through a dozen roadblocks with the help of a translator, the group’s next obstacle appeared. Sheets of torrential rains pouring down over the Land Rover sent its four wheels plunging into the mud. Each time the car got stuck, Breman and the others got out to push—a move that instantly drenched the paper gowns and masks they'd worn as protection. Knee deep in mud, sweat mixing with rain, they forced the Land Rover through the jungle. “I was absolutely terrified,” says Breman. “You’re soaked. Afraid. Just trying to do your work.”
The first stop in the jungle was the Yambuku mission, where three “angelic-looking” nuns were huddled near makeshift crime-scene tape that they’d strung around the local hospital.
It was here, six weeks earlier, that the virus had emerged. The mission’s 44-year-old school headmaster had come down sick with a fever after traveling north for vacation. Everyone assumed he’d contracted malaria. Inside the hospital, he was injected with malaria medication using unsterilized needles. When the medicine didn’t help, and his condition deteriorated, the staff began to worry. Less than two weeks later, he was dead. The women who prepared his contagious body for burial were soon infected, as were the clinicians and family members who had treated him, and the dozens who had come in contact with the needles. Of the hospital’s 17 staff members, 13 became sick and 11 died. By the time Breman arrived, the three nuns and one old priest were all that remained of the mission.
In the weeks since the headmaster’s bizarre illness, the nuns had done their best to record the disease’s symptoms. But there were hundreds of victims and keeping track of each death grew difficult. Making village visits shortly after arrival, Breman saw his first Ebola victim.
The man was young, in his 20s or 30s, “good looking,” and visibly afraid. Surrounded by family and friends, he sat shirtless and motionless leaning forward in a chair on the dirt in front of his hut. When Breman asked to examine him, he was too sick to answer. “Tell me what’s going on,” Breman said. The pain was so excruciating that talking was difficult for the man. Severe belly pains, a headache, and fever were the only conclusions Breman could draw. There was little more the doctor could do. “I gave him all the medicine we had to keep him comfortable, told his family to keep him in the house,” but not to let others have contact except one person to bring him food and water. Two days later, he was dead. “You just keep going on,” Breman says with a sigh. “Try to figure out how far the disease had spread.”
Seventy-two hours into his trip, and Breman had already stared the virus in the face. The CDC’s “just a few days” window was fast closing. But his work was far from finished. The days would soon turn into months.
There wasn’t much time to rest or think. Breman tasked 10 four-person teams with visiting all 550 villages in the Bumba Zone twice. The 55 villages with confirmed infections were visited an additional time, to be safe. “People along the road from the main town …were relieved when we said we’d come to stop the disease’s spread, treat patients, and meet their families,” Breman wrote in a recent New England Journal of Medicine paper.
In many places, it was custom to place huts outside the villages for smallpox victims. Breman encouraged families to use this practice for the new virus, and designate just one person (preferably someone who had already survived the virus) to deliver food and water. Dead bodies were to be covered in bleach, and typical burial rites of kissing and touching ignored. A burning hut meant it was contaminated with the virus. A shaved head meant the microbe had stolen a loved one.
On every trip to a village, a hospital, a hut, Breman and the others carried an invisible burden: they could be next. “We didn’t know how it would spread,” says Breman. “So we started monitoring ourselves.” Breman instructed the group to take their temperatures twice a day and report immediately if it spiked. “You’re absolutely terrified that you will get this because, at this time, we didn’t how patients got it,” says Breman. With sweltering hot temperatures, constant sweat was normal. “We were careful with how we dealt with suspected patients and what we did with our primitive coverings, it was steamy.” Sometimes, when perspiring heavily and feeling warm Breman would fear the worst. When his fever came back to normal, he’d find himself fixating on sand-fly bites instead. “You wonder, is this a rash? What does this mean?” Long days of hiking from village to village exhausted the group; a lack of clarity regarding the virus’s origins and how it spread almost sent them over the edge.
In all, the 1976 outbreak saw 318 cases in Zaire, 280 of which ended in death. The epidemic had peaked before Breman’s arrival. The majority of the early cases were traced back to unsanitary needles. Towards the conclusion of the trip, Breman discussed the new virus with Johnson. At that time, all new viruses were being named after the region in which they occurred. But this virus, so graphic and deadly, would lay a severe stigma on whatever village, land, or country shared its name. So Johnson thought of something else. “He said, ‘Why don’t we not stigmatize Yambuku,’” Breman remembers. “Why not name it after a geographical area instead?” The name, taken from a small river in Northern Zaire, is more famous now than Breman ever imagined it would be: Ebola.