Tom Clynes

Saturday morning at the hospital guest house, Tony Sanchez and Pierre Rollin are finishing breakfast, getting ready to suit up for the lab. Since arriving in Gulu they’ve been occupied controlling the outbreak; they’re hoping to soon shift their focus from containment to research.
“You can’t do productive field research on Ebola when it vanishes,” says Rollin. “So you need to get the information when you can.”
Researchers at the National Institutes of Health recently announced progress in developing an Ebola vaccine that works in monkeys, but the virus’s underlying logic is still beyond the reach of science. Since coming to the world’s attention in 1976, the disease has baffled a generation of researchers, who have collected hundreds of thousands of specimens from plants, animals, and insects. Humans are what research virologists like Sanchez and Rollin call “accidental hosts” for the Ebola virus. “We don’t know where it hides,” Rollin says. “It may turn out to be something right under our noses. There are different schools of thought. Some say it is carried by rodents, or insects, or bats . . .”
At that moment, as if summoned, Bob Swanepoel strides into the dining room decked out in a beige bush-hunter outfit. Swanepoel is a bat man. The director of the Special Pathogens Unit of the South African Institute for Virology, the goateed, 64-year-old virologist has made a career out of tramping to Africa’s remote jungles, looking for the reservoirs for Ebola and other hemorrhagic fevers.
“He’s at every outbreak,” says Rollin. Over the past 20 years, Rollin and Swanepoel have developed a bond that’s fed by a shared fascination for viral diseases. When they’re not working together at an outbreak, they communicate over the phone, from Atlanta to Johannesburg, at least once a week.
Swanepoel was in Saudi Arabia at the Rift Valley fever epidemic when the first samples of Ebola-infected blood, sent by Lukwiya, arrived at his Johannesburg lab. Now, a month later, he has finally arrived in Gulu, with two assistants and several bundles of nets and poles. “Pierre told me not to come,” he says, settling in at Rollin’s table. “He said there is nothing here, that we’re too far downstream in the epidemic. But what do you do when you hear that? Do you stay home? No, you have to see for yourself.”
Swanepoel is eager to do some reservoir hunting, but his bat-nabbing nets remain bundled outside his room. “Right now,” he says, “there are several hurdles. First, I need to know the focal point before I start trapping. Did one person get it first, or were there a lot of people who separately picked up this thing from nature? It’s the Sudan strain of Ebola, but was it brought in by a rebel from Sudan, or did it start near here? Northern Uganda and southern Sudan have roughly the same terrain and ecology, and the entire region is like a Bermuda Triangle of filoviruses. We’re close to the Ebola River, to Durba, Mount Elgon, Kitum Cave—all the hotbeds of Marburg and Ebola.
“The second hurdle is, I need approval. You go out in a place like this without approval, and the next thing you know you’re into ten kinds of sh--. We got arrested in Congo, and it took half a day before they tracked down the colonel to vouch for us. He was at a brothel.
“Third, there are security issues. It’s best to work at night, but . . .”
Rollin finishes Swanepoel’s sentence: “But if you put a net up at night, you’re more likely to catch a rebel than a reservoir.”
Rollin often raises an eyebrow when he talks, which gives him a wizened, slightly comical look. “What I would like to know,” Rollin says, “is did somebody do something in the bush that people don’t normally do? Something seemed to be happening in September, before Matthew arrived. There was a lot of diarrhea, and rumors about some unusual malaria in a certain village. What you want to find is, was there a village where it started? But because of stigma, and because so much time has passed and so many people are dead, you don’t get the straight story.”
As Rollin talks, a dark spot forms above his left eyebrow. No one says anything, but in a minute, Rollin feels the liquid as it starts to run down his forehead. He wipes it with his index finger.
“Hmm. It’s blood. Very strange. I don’t think I cut myself here. And I haven’t shaved my forehead lately.”
He wipes it away. When it keeps coming, he gets up and grabs a tissue. He succeeds in stanching the flow and sits back down. All conversation has stopped.
“Maybe I have started to bleed with Ebola a new way,” he says, smiling as he raises an eyebrow. And everyone laughs. Nervously.

After breakfast, Tony Sanchez walks out of the guest house, toward the lab. An ambulance pulls around the corner, and Sanchez averts his eyes as an Ebola suspect is led into the ward.
“What we don’t experience up in Atlanta is the wards, the bleeding,” he says. “I talked to Pierre about what to expect, but to tell you the truth, I’ve never seen large numbers of people dead and dying before—and the way they suffer . . . During the day you’re doing your job, and you don’t think about it. But at night you see their faces. Your subconscious comes up with questions you can’t answer.”
Brother Elio Croce calls Sanchez’s name and trots over. A Verona father who runs Lacor’s technical and transportation services, Brother Elio is a plump Sean Connery look-alike with a compassionate demeanor balanced by a cranky sanctimoniousness.
“Tony, I need to take you out to Bardege Village,” Elio says, “to get blood and a skin sample for a biopsy from a little girl who just died. We need to get there before they bury her.”
With Elio is a soldier named Gordon Biforo, from Mbarara, in Uganda’s southwest. He’s the one who was vomiting in the armored personnel carrier last night.
“I had been feeling poorly from malaria,” the soldier says. “I had a bottle of orange Mirinda soda, and it came right up. It looked like blood so the others got scared.” The hospital gave him quinine and took some blood just in case, but he looks fine. Elio asks him if he’s angry with his army buddies for running away.
“I am sure I would have run too,” he says.
I introduce myself to Brother Elio and extend my hand—it’s amazing just how reflexive the custom is. Before I realize my mistake, Elio reaches out, grabs my hand, and looks me straight in the eye. “We’re not shaking hands here anymore,” he says, shaking my hand. “There’s an Ebola epidemic going on here you know.”
Actually, the Gulu epidemic was initially spread more by contact with the dead than with the living. According to local ritual, a dead body must stay in the house for a day or two while extended family and friends wash the corpse, eat and drink, and wash their hands in a communal basin. Then they bury the body next to the house.
“For you, the dead take care of themselves,” James Kidega had told me earlier. “For us, we take care of the dead.”
The viral count is at its peak in a just-expired body, but despite the risk and despite an aggressive education campaign, it’s been extremely difficult to get people to stop customs that have been entrenched for generations. For that reason, health workers have encouraged residents to report deaths in neighboring families.
Sanchez grabs his gear and jumps into the truck with Elio. As Elio drives, he talks nonstop in a sing-songy Italian accent that seems incongruous with the content of his monologue.
“The nurse, Grace Akulu, died. She was conscious until the very end—it’s not true that everyone is demented in the final stages. She died singing; she never feared to encounter our Lord. We buried her behind the hospital in a beautiful ceremony. I have tape-recorded the singing. I will play it for you later.”
“I thought it was supposed to be slowing down,” Sanchez says.
“I do not think it is slowing down now, Tony.” Elio says. “Tomorrow, we have to dig more graves.”
With the isolation ambulance trailing, Elio turns off the road and drives through the elephant grass, following a single-track trail that terminates in a tidy dirt courtyard surrounded by a half dozen round mud-brick huts with thatched roofs.
The deceased girl’s name is Sunday Onen; she was two years old. Her mother sits next to two other women who are nursing young children, while her grandfather, a well-spoken man named Peter Ola, talks to Sanchez and Elio.
“The child was healthy,” he says incredulously. “She ate breakfast around nine, then she had a fever and began vomiting. When her diarrhea became bloody, my daughter began to carry her to the hospital. But midway, she did not cry out any longer, so she brought her back here.”
Ebola doesn’t usually work that quickly, but there are enough Ebola symptoms that this must be treated as a suspect case. The villagers watch in silence as Sanchez suits up; the three ambulance crew members stand in the sun, sweating inside their protective clothing.
As Sanchez bends down and leans into the hut, Brother Elio pulls out his tape recorder and begins a peculiar commentary from outside.
“He’s down on one knee, entering the hut. Yes, that’s it, careful.”
Encumbered by the hut’s darkness and his layers of protective gear, Sanchez draws blood and cuts a skin sample from the tiny corpse. It takes longer than it should, because the lab has run out of biopsy punches, devices that work like high-tech cookie cutters to neatly remove a small patch of skin. He has to tug the girl’s skin up, then make the cut with surgical scissors, working slowly, with full awareness of the consequences of even the smallest nick to his hands.
“He’s down on both knees now,” Elio continues. “Yes. Respect. Respect.”
Sanchez backs out of the hut and straightens up, breathing hard through his surgical mask. He walks to the center of the clearing and lays out a sheet of white cloth, then he kneels down to pack the specimens. An ambulance crew member comes over with a garden-pump dispenser of disinfectant and sprays the bottoms of Sanchez’s feet. Then the sprayer follows the other two crew members into the hut. Sanchez stands up just as the three of them emerge, carrying a small white bundle.
“My God,” Sanchez says. “I thought this was going to be an easy day.” I notice that his right hand is twitching.
As the body is brought to the ambulance, the villagers suddenly become agitated. They gather around Brother Elio, talking to him in the Acholi language. Elio approaches Sanchez.
“See the problem now, Tony,” he says, “there’s been a misunderstanding. They thought that we would come out and test the girl, and if it wasn’t Ebola, we would leave her here for them to bury her according to tradition.”
Sanchez does his best to explain that he needs to bring the blood and tissue back to the lab to test for the Ebola antibody. The test takes several hours, and it may not be conclusive. They need to send the skin samples away for testing in Atlanta. The whole village may be vulnerable to infection if the body is not taken away and buried at the isolation graveyard.
After a few minutes, the villagers stop talking; they just stare at Sanchez, the white man in the white suit insisting that their loved one be sent off to the afterlife unprepared—buried as if she had never lived at all.
Sanchez takes Elio aside, and the two men’s roles flip-flop. Sanchez, the scientist, wants to compromise, to humanize the rules. The body was in good condition, he says. It may not have been Ebola. Maybe it was a snake bite. . . .
“But the grandfather said she did not cry out,” Elio says, sharply. Sanchez’s hand twitches again.
“What are we going to do?” he asks.
“We’re not going to do anything,” Elio snaps. His face is pinched, and the words come out that way, in a clipped staccato. “We can’t let them bury her here. They will not do it the way we want.”
We move toward the truck, and the villagers follow, forming a crescent around the front of the vehicle, continuing to stare as we get in. It feels as if the air has been sucked out of the sky.
Elio starts the truck and shifts it into reverse. He begins to let out the clutch—then he stops.
“Hey,” he says, looking at Sanchez. “What do you think? We let them bury her here. We stay, we supervise, they dig the grave very fast. It’s more human, no?”
In an instant, they’re out of the truck. Elio makes the announcement and the dirt starts flying, with Sunday’s father, who couldn’t be more than 17 years old, leading the dig. A half hour later the hole is completed, two meters deep. And the ambulance crew lowers Sunday Onen’s body gently into the ground.

On Saturday night, the team gathers in the courtyard at the Acholi Inn, tucked behind the roofless carcass of a burned-out building on the northern edge of town. Under a canopy of trees thick enough to block a light rain, a waitress runs back and forth with food and rounds of the local beer, Nile Special, politely requesting that the foreigners not lean back on the rear legs of the fragile plastic chairs. As the shadows lengthen, monkeys and an occasional rat scurry around the garden’s perimeter; after sunset, bats swoop among the overhead branches.
Even the Nobel Peace Prize-winning Doctors Without Borders is perennially short of recruits who are willing to turn their backs on comfortable, lucrative careers to come to needy places like Gulu, where the patient-to-doctor ratio approaches 18,000 to one (in the United States it’s about 400 to one). Yet despite the high stress and low comfort, despite the sound of machine-gun fire in the night, everyone seems to feel privileged to be here.
“I had been wanting to do something like this since I was a teenager,” says Patricia Campbell, an American physician with Doctors Without Borders. “I saw medicine as a passport to the world. But then I got married and had children, so I had to put it off until my kids were older.” Now in her mid-60s, Campbell says she’s “addicted.”
“I go home to Scarsdale [New York], and I wonder how anyone can stand it, treating rich kids for tonsillitis. After a few weeks, I’m saying, ‘Get me out of here!’”
The obvious question: Are you afraid?
“No,” Campbell says flatly. “You follow protocol. Unless you’re in direct contact with body fluids, you won’t get Ebola.”
Murmurs of agreement wash over the table. “If there was that high of a risk,” says Simon Mardel, “I wouldn’t be here.”
Of course, playing down the risks is a coping mechanism, a way of keeping panic at bay. Like cigarette-smoking (most of the doctors do) or gallows humor, denial keeps you functioning effectively in the presence of danger and death—whether you’re a doctor in a plague zone or a soldier in a battle zone.
For all the talk about managing risk, though, the odds don’t look very good for medical people in their ongoing battle with the Ebola virus. In the 1995 Ebola outbreak in Congo, 80 medical workers became infected; 63 died. Hospitals—especially deprived African hospitals—provide an ideal environment for the virus to prosper, and health workers are vulnerable targets because of their close contact with bodily fluids. As would soon become devastatingly clear to everyone on the team, Ebola does not forgive even the smallest mistake.

On Sunday morning, grief takes a holiday. James Kidega walks through the double doors of Christ Church, and joins the congregation in the throes of a full-blown dance party. At the front of the low altar, a band of musicians strum away on stringed gourd instruments; they’re nearly drowned out by a platoon of drummers, whacking away in a polyrhythmic fury. Around the musicians and into the back pews, people of all ages pogo up and down, driven in a raucous call and response by a young woman croaking through a distorted P.A.
“The love of Jesus has taken away the sins of the people,” she sings.
“Evil can’t touch us!” the dancers cry.

Two of the 11 Kenyans have tested positive for the Ebola antibody, indicating exposure to the virus. It’s not clear whether they are ill or not, nor how much contact they’ve had with others. And it’s not clear whether the Kenyan government has quarantined them. Pat Campbell is already on her way to Kenya.
The road north to Atiak is closed due to artillery fire, and a volunteer has destroyed one of the trucks in a rollover accident. The rental company has demanded the return of a van, after discovering that it’s being used in the plague zone. “We’ve tried begging,” says Derek Hardy, who handles logistics, “and it hasn’t worked. Now we’re going to try to stall.”
A few minutes later, Hardy is barking into the radio: “We need an infant feeding bottle, five teats, and a dozen cans of formula.”
“Have them bring it all to the Gulu Hospital,” Roth says.
Apparently, a woman who died yesterday had a baby just before coming to the hospital. The baby, now with the grandmother, is probably Ebola-positive and without proper care. Roth is hoping to convince a woman who recovered from Ebola but lost her baby to serve as a wet nurse or an adopter. The recovered woman should have antibodies that will make her immune to reinfection.
“It’s a bit of a tough sell,” Roth says, “so we’ve got to get someone really good to talk to her, maybe a nurse who was with her at Lacor.” In the meantime, Aikichi Iwamoto, a Japanese doctor, will go out to the village with infant formula to attend to the newborn.

Outside his guest room in a wooded corner of the lacor hospital compound, Bob Swanepoel slouches in a chair, flinging pebbles into the trees with a wrist-rocket slingshot. Nearby, Pierre Rollin sits on the concrete floor, his back against the door, his legs stretched in front of him. Someone brings over a straw-colored fruit bat killed by a local boy, and Swanepoel perks up.
“These things are vicious,” Swanepoel says, spreading the bat’s wings. “Look at these teeth, and these claws—they’re like razors. They’ll go after you like a dog.” He asks one of his researchers to put it in the fridge, along with a cobra that was killed on the Lacor grounds yesterday after menacing some nurses.
Swanepoel’s bat-trapping expedition has been approved, but he’s pessimistic about what the fieldwork might turn up. Without knowing where the epidemic started, he says, “it’s a shot in the dark.”
“Also, we’ve learned that the caves in the Kalak Hills aren’t what we thought they were. Apparently, there are lots of very narrow caves that are difficult and dangerous to navigate. Maybe we can go up to the top and drop the nets—I don’t know.”
Brother Elio rides up on his bike. He wants Rollin to test him for Ebola.
“That will be the third time you’ve been tested,” says Rollin. “You keep thinking you’re infected.”
“We lost another nurse today,” Elio says. “That makes eight, plus a nurse’s boyfriend. We can’t figure out how the boyfriend was exposed, since the nurse did not get Ebola. He was a young man, and strong. At the end, he told me he wanted to get married before he died, so I got the priest and sent for the girl. But, as she was on her way here, we realized that we had time only to give him his last sacraments. When she arrived, the father went out to meet her.” Elio pauses.
“He told her that he had already left for the long safari.”

At headquarters, Derek Hardy is on the porch, having a smoke, when the rental van rolls in with Aikichi Iwamoto, back from his baby-formula mission. He’s sure the baby is Ebola-positive, but he’s not a pediatrician, and he didn’t have a needle small enough to take a sample. Her condition, he says, is “very grim.”
He shuffles onto the porch and asks Hardy for a cigarette.
“I didn’t know you smoked, Aichi,” Hardy says.
“I just started again.”
Cathy Roth comes out and announces that she’s “cancelled the cancellation of this afternoon’s meeting.” Everyone troops inside.
There have been five deaths today, so far. The CDC’s Scott Harper reports that six people were admitted yesterday, and they aren’t on any contact lists. “People seem to be hiding family members,” he says; “the system seems to be breaking down. In Atiak, a suspect was buried, and no one got a specimen.”
In Pabo, some recovering patients have been lost. At Gulu Hospital, an Ebola-positive patient “escaped” last night. (He later turned up at Lacor.) As for the miscarriage, there are now 32 contacts, including 11 health-care workers. There were two deliveries after the infected woman’s, on the same table.
Dr. Paul Onek, the district health officer, gives voice to everyone’s frustration. “If we have escaped patients, if we are not even able to take specimens from deceased people, then we are back to square one.” He is silent for half a minute, then he speaks. “Yesterday, we breathed a sigh of relief. But now . . .” He purses his lips and sighs. There’s no relief in it.

After the church service, James Kidega travels across the field where the Pope spoke, and approaches a cluster of huts. The witch doctor, Abodtu, is in, although the authorities ordered him to remove his “traditional African healing” banner after a witch doctor in Rwot Obilo treated—and possibly infected—up to 30 people before dying of Ebola.
But Abodtu doesn’t claim to cure Ebola—at least, not yet.
“Right now, I have no medicine for this,” he says, lighting a candle. “I cure people who are lame, or berserk. I make the leg stop swelling, and the brain start working. Or, I send death to someone who has done wrong to your family.
“As for the white man’s medicine and the white man’s religion, I do not cross there. This is what I know.” He sweeps his eyes toward his altar—a clutter of beads and bones, snake skins and rattles, jugs and strings of shells.
Where does Ebola come from?
“I have asked my bad-thing where it came from. The spirit tells me to wait for instructions, then to go to the forest and look up to a special big tree. This tree has the answer; it will tell me where it comes from.” He inhales deeply. “I will look up to the tree, and I will learn from the tree how to stop it.”

Continue to Conclusion.