1980 January 24
Nine days after the patient vomited into Dr. Shem Musoke’s eyes and mouth, Musoke developed an aching sensation in his back. He was not prone to backaches—really, he had never had a serious backache, but he was approaching thirty, and it occurred to him that he was getting into the time of life when some men begin to get bad backs. He had been driving himself hard these past few weeks. He had been up all night with a patient who had heart problems, and then, the following night, he had been up most of the night with that Frenchman with hemorrhages who ha come from somewhere upcountry. So he had been going nonstop for days without sleep.
He hadn’t thought much about the vomiting incident, and when the ache began to spread through his body, he still didn’t think about it. Then, when he looked in a mirror, he noticed that his eyes were turning red.
Red eyes—he began to wonder if he had malaria. He had a fever now, so certainly he had some kind of infection. The backache had spread until all the muscles in his body ached badly. He started taking malaria pills, but they didn’t do any good, so he asked one of the nurses to give him an injection of an antimalarial drug.
The nurse gave it to him in the muscle of his arm. The pain of the injection was very, very bad. He had never felt such pain from a shot; it was abnormal and memorable. He wondered why a simple shot would give him this kind of pain. Then he developed abdominal pain, and that made him think that he might have typhoid fever, so he gave himself a course of antibiotic pills, but that had no effect on his illness. Meanwhile, his patients needed him, and he continued to work at the hospital. The pain in his stomach and in his muscles grew unbearable, and he developed jaundice.
Unable to diagnose himself, in severe pain, and unable to continue with his work, he presented himself to Dr. Antonia Bagshawe, a physician at Nairobi Hospital. She examined him, observed his fever, his red eyes, his jaundice, his abdominal pain, and came up with nothing definite, but wondered if he had gallstones or a liver abscess. A gall-bladder attack or a liver abscess could cause fever and jaundice and abdominal pain—the red eyes she could not explain—and she ordered an ultrasound examination of his liver. She studied the images of his liver and saw that it was enlarged, but, other than that, she could see nothing unusual. By this time, he was very sick, and they put him in a private room with nurses attending him around the clock. His face set itself into an expressionless mask.
This possible gallstone attack could be fatal. Dr. Bagshawe recommended that Dr. Musoke have exploratory surgery. He was opened up in the main operating theater at Nairobi Hospital by a team of surgeons headed by Dr. Imre Lofler. They made an incision over his liver and pulled back the abdominal muscles. What they found inside Musoke was eerie and disturbing, and they could not explain it. His liver was swollen and red and did not look healthy, but they could not find any sign of gallstones. Meanwhile, he would not stop bleeding. Any surgical procedure will cut through blood vessels, and the cut vessels will ooze for a while and then clot up, or if the oozing continues, the surgeon will put dabs of gel foam on them to stop the bleeding. Musoke’s blood vessels would not stop oozing—his blood would not clot. It was as if he had become a hemophiliac. They dabbed gel foam all over his liver, and the blood cam through the foam. He leaked blood like a sponge. They had to suction off a lot of blood, but as they pumped it out, the incision filled up again. It was like digging a hole below the water table; it fills up as fast as you pump it out. One of the surgeons would later tell people that the team had been “up to the elbows in blood”. They cut a wedge out of his liver—a liver biopsy—and dropped the wedge into a bottle of pickling fluid and closed up Musoke as quickly as they could.
He deteriorated rapidly after the surgery, and his kidneys began to fail. He appeared to be dying. At that time, Antonia Bagshawe, his physician, had to travel abroad, and he came under the care of a doctor named David Silverstein. The prospect of kidney failure and dialysis for Dr. Musoke created a climate of emergency at the hospital—he was well liked by his colleagues, and they didn’t want to lose him. Silverstein began to suspect that Musoke was suffering from an unusual virus. He collected some blood from his patient and drew off the serum, which is a clear, golden-colored liquid that remains when the red cells are removed from the blood. He sent some tubes of frozen serum to laboratories for testing—to the National Institute of Virology in Sandringham, South Africa, and to the Centers for Disease Control in Atlanta, Georgia, U.S.A.
Then he waited for results.
DIAGNOSIS
David Silverstein lives in Nairobi, but he owns a house near Washington, D.C. One day in the summer recently, when he was visiting the United States to tend to some business, I met him in a coffee shop in a shopping mall not far from his home. We sat at a small table, and he told me about Monet and Musoke cases. Silverstein is a slender, short man in his late forties, with a mustache and glasses, and he has an alert, quick gaze. Although he is an American, his voice carries a hint of Swahili accent. On the day that I met him, he was dressed in a denim jacket and blue jeans, and he was nicely tanned, looking fit and relaxed. He is a pilot, and he flies his own plane. He has the largest private medical practice in East Africa, and it has made him a famous figure in Nairobi. He is the personal physician of Daniel arap Moi, the president of Kenya, he travels with President Moi when Moi goes abroad. He treats all the important people in East Africa: the corrupt politicians, the actors and actresses who get sick on safari, the decayed English-African nobility. He traveled at the side of Diana, Lady Delamere, as her personal physician when she was growing old, to monitor her blood pressure and heartbeat (she wanted to carry on with her beloved sport of deep-sea fishing off the Kenya coast, although she had a heart condition), and he was also Beryl Markham’s doctor. Markham, the author of West with the Night, a memoir of her years as an aviator in East Africa, used to hang out at the Nairobi Aero Club, where she had a reputation for being a slam-bang, two-fisted drinker. (“She was a well-pickled old lady by the time I came to her.”) His patient Dr. Musoke has himself become a celebrity, in the annals of disease. “I was treating Dr. Musoke with supportive care” Silverstein said to me. “That was all I could do. I tried to give him nutrition, and I tried to lower his fevers when they were high. I was basically taking care of somebody without a game plan.”
One night, at two o’clock in the morning, Silverstein’s telephone rang at his home in Nairobi. It was an American researcher stationed in Kenya calling him to report that the South Africans had found something very queer in Musoke’s blood: “He’s positive for Marburg virus. This is really serious. We don’t know much about Marburg.”
Silverstein had never heard of Marburg virus. “After the phone call, I could not get back to sleep,” he said to me. “I had kind of waking dream about it, wondering what Marburg was.” He lay in bed, thinking about the sufferings of his friend and colleague Dr. Musoke, fearful of what sort of organism had gotten loose among the medical staff at the hospital. He kept hearing the voice saying, “We don’t know much about Marburg.” Unable to sleep, he finally got dressed and drove to the hospital, arriving at his office before dawn. He found a medical textbook and looked up Marburg virus.
The entry was brief. Marburg is an African organism, but it has a German name. Viruses are named for the place where they are first discovered. Marburg is an old city in central Germany, surrounded by forests and meadows, where factories nestle in green valleys. The virus erupted there in 1967, in a factory called the Behring Works, which produced vaccines using kidney cells from African green monkeys. The Behring Works regularly imported monkeys from Uganda. The virus came to Germany hidden somewhere in a series of air shipment of monkeys totaling five or six hundred animals. As few as two or three of the animals were incubating the virus. They were probably not even visibly sick. At any rate, shortly after they arrived at the Behring Works, the virus began to spread among them, and a few of them crashed and bled out. Soon afterward, the Marburg agent jumped species and suddenly emerged in human population of the city. This is an example of virus amplification.
The first person known to be infected with Marburg agent was a man called Klaus F., an employee at Behring Works vaccine factory who fed the monkeys and washed their cages. He broke with the virus on August 8, 1967, and died two weeks later. So little is known about the Marburg agent that only one book has been published about it, a collection of papers presented at a symposium on virus, held at the University of Marburg in 1970. In the book, we learn that
The monkey-keeper HEINRICH P. came back from his holiday on August 13th 1967 and did his job of killing
