We all fall down, p.5
We All Fall Down, page 5
Aside from Byron, four other members of the WHO task force are squeezed around the table among the Italian officials. The highest-ranking is the country’s deputy minister of health, a doughy-faced man who has thus far remained silent.
The table is so crowded that Alana’s knee keeps brushing against Nico’s. His cologne is a constant distraction. She hasn’t shared this kind of proximity with him since that last morning in Palermo when they lay naked and winded in the four-poster bed, plotting out future reunions that were never to materialize.
It’s been over eight years, Alana reminds herself. There have been other relationships since, two of which lasted longer. She came close to marrying the last man, a gentle but, as it turned out, insufferably idealistic water engineer whom she had met in Geneva. But Nico was different. He was her first love after her shoulder injury, and their romance hadn’t sputtered out like most of the others had. They had chosen their careers, which kept them constantly separated in different hot spots across the globe, over their relationship.
Byron’s voice pulls her back to the meeting. “Just to review: the plague is spread by the rat flea, or Xenopsylla cheopis, which transmits bacterium through its bite.” He clicks the remote in his hand and the screen above him fills with the image of a golden translucent creature that resembles a lobster without claws. “These fleas require an animal vector, or carrier, to ‘host’ them. That can be almost any mammal, especially rodents like rats, mice, squirrels, or even prairie dogs. But in most cities the plague is usually spread by the black rat.” The slide above him dissolves and re-forms as a photo of a mischief of rats, clumped together and crawling over one another. The image, although static, gives Alana a queasy sense of movement.
“As most of you know, there are three clinical variants of the plague,” Byron continues. He speaks in English, not allowing time for translation, even though this meeting is in Genoa to discuss an Italian outbreak. “All are caused by the same bacterium: Yersinia pestis. The most common form is the bubonic plague, which presents with classic skin buboes, or swollen lymph nodes, that are discolored from internal bleeding.” The next slide is that of a wide-eyed young boy whose neck is distended on both sides by darkish lumps. “But there are two other, even deadlier forms. The rarest is a type of blood poisoning known as the septic plague.” The body of a pale, thin woman, with a bar drawn across her eyes to hide her identity, fills the screen. Her skin is riddled with small purplish red spots, known as purpura. Both her legs are blackened from the knees down with the patches of dead skin or necrosis, and it’s obvious to Alana the photo was taken postmortem. “And, of course, the other form is known as the pneumonic plague, which attacks the victims’ lungs . . .” The screen comes to life with a grainy video clip. A middle-aged man writhes on a hospital bed. His cough is so harsh it almost made Alana hack. Even though he covers his mouth with a hand, bloody sputum sprays between his fingers with each violent hack. “Both the septic and pneumonic plagues are uniformly fatal without early and aggressive antibiotic treatment.”
Byron lets the uncomfortable clip run on a bit longer than necessary, Alana thinks, before the screen finally goes blank. “The bubonic plague only spreads through infected fleabites, not via person to person,” he says. “The pneumonic plague can begin as a skin infection, with the usual buboes, that travels to the lungs. However, more commonly it spreads from one person to the next through coughing, and it’s as contagious as the flu. So far, we have two confirmed cases of pneumonic plague in Genoa. Patient Zero is a forty-two-year-old construction worker who presented four days ago. She developed her first skin symptoms, buboes in her armpits, two days prior to hospitalization. Once there, she had direct contact with the second case, a thirty-one-year-old lab tech. The second victim had no skin involvement of any kind, only chest symptoms. She, like Patient Zero, died from respiratory complications.”
“So we can presume respiratory spread from the first victim to the second,” Nico says.
“We can, I suppose,” Byron says with a cursory glance at him. “It doesn’t mean we would be correct to do so.”
“We would be foolish not to,” Nico fires back.
“Foolish . . .” Byron grins. “Say, like not immediately placing a feverish woman who presents to hospital coughing up blood on full isolation precautions?”
“Easy to say in hindsight,” Nico snaps. He turns to the person on the other side of him and mutters something in Italian, loud enough to be heard by everyone. The room erupts into a medley of unintelligible voices.
Byron holds up his hands. “Point taken,” he says, in the tone of someone appeasing an irrational toddler. “You were astute to diagnose the plague. Besides, what’s done is done. Why don’t we finish taking stock before we move on to the next steps?”
There are a few reluctant nods and the din settles.
“We do not as of yet have a confirmed source for the Yersinia pestis bacteria,” Byron continues. “We do know that Patient Zero traveled to Menagesha National Forest in Ethiopia twenty days prior to showing her first symptom.”
“And that park is chockablock full of high-risk critters,” Dr. Justine Williams pipes up. The petite woman of Asian descent with the dark eyes and long lustrous black hair has made an impression with her job description alone—Alana had never before met a rodentologist, let alone “one of the world’s leading zoologists in the study of rat behavior,” as Byron had introduced her.
“All kinds of potential endemic plague vectors could be hiding among those lovely juniper bushes,” Justine continues. “From Desmomys harringtoni—better known as Harrington’s rat—to Praomys albipes, aka the white-footed rat. Though their feet aren’t any whiter than mine.” Her giggle is almost contagious. “And don’t forget, our dear old friend Rattus rattus—the common black rat—is also found in the same park. Word on the street is that black rats have had a brush or two with the plague in the past.”
Byron eyes Justine with a mixture of amusement and annoyance. “The usual incubation period for the plague is two to seven days, not twenty,” he says.
Justine shrugs. “Bugs mutate. Shit happens.”
“There hasn’t been a case of bubonic plague reported in Ethiopia—in man or animal—in over twenty years. Besides, the two cases in Genoa have behaved far more aggressively than any of the ones seen in Africa recently.”
“See my earlier point about mutation . . . and also . . . shit happening.”
The deputy minister raises his hand. “Dr. Menke, a question, if you will allow me?”
“Of course.”
“Are you saying that this outbreak did not originate in Africa?”
“No. Not yet, at least. As Dr. Williams points out, there are all kinds of mammals living in that ecosystem, including black rats. We also know that the rat flea is endemic to the same park. We’ve got a WHO team on the ground in Ethiopia collecting samples at the national park, and we should know better in the coming days. Meantime, all I’m saying is that we have no confirmed source and we shouldn’t presume anything.”
“But if the so-called Patient Zero was not infected on her trip to Africa, then she could only have acquired it here in Genoa.”
“It is too early to know.”
“Where else could it possibly come from?” the deputy minister persists. “There have been no such infected animals in Italy for hundreds of years!”
“Underestimate the ingenuity of rats at your own peril,” Justine says. “To them, intercontinental travel is little more than a jaunt in the park.”
Alana can’t hold her tongue any longer. “How do we know the first victim became infected through a rat or any other animal vector?”
All eyes turn to her. “Would our NATO colleague care to elaborate?” Byron asks.
Alana introduced herself only as an infectious diseases colleague of Nico’s, but she realizes it’s not the time or place to confront Byron for calling her out. “As you said yourself, Dr. Menke, we can’t presume anything about the source,” she says calmly. “Including that there ever was a zoological source. Or, for that matter, that the person whom you’re calling ‘Patient Zero’ is in fact the index case.”
Byron holds her gaze for a moment, and then looks around the table. “I think we can all agree that, whatever the source, containment is now the top priority.” Heads nod and there are murmurs of concurrence. “To that end, we need to start every casual contact of both known victims on antibiotics.”
“We have already done so at the hospital,” says Dr. Sansa, a distinguished-looking older man who was introduced as the city’s chief Public Health officer. “Everyone who had direct contact with the victims has been started on doxycycline and ciprofloxacin, or some alternative if allergic.”
“What about immunization?” Nico asks.
Byron motions across the table to a man with reddish blond hair and a boyish face, whose bushy beard makes him somehow look even younger. “For that I will defer to our immunization expert, Dr. Larsen.”
Larsen removes his glasses. “The World Health Organization does not, as of yet, have ready access to mass quantities of Yersinia vaccine.”
“But the U.S. military does,” Alana says.
“Even their capacity is limited. Besides, the plague vaccine is notoriously unreliable, with post-exposure immunity rates of only seventy-four percent. It would leave roughly three out of ten people unprotected.”
“Better than ten out of ten,” Alana points out.
“Also, the vaccine doesn’t offer any proven protection against exposure to the pneumonic plague. Only post-exposure antibiotics are effective. And they must be given within twenty-four hours.”
“Nonetheless,” Byron says. “We will expedite access to the vaccine, prioritizing the health care workers on the front line and in the lab. Meantime, we need to focus on aggressive contact-chasing. Find anyone and everyone who might’ve been within a stone’s throw of a plague victim.”
Dr. Sansa nods gravely. “We have been doing little else. Around-the-clock.”
“Good,” Byron says. “There is one other vital aspect we need to agree upon. Communications. It’s a miracle this story hasn’t hit the mainstream media. But it will. And soon.”
Sansa exhales. “Our office received several calls this morning.”
“It’s essential we get ahead of the media and control the message, rather than vice versa. To that end, I’ll turn to our communications specialist, Yvette Allaire, to review the fundamentals.”
“Thank you, Byron,” says a painfully thin Frenchwoman at the far end of the table. Alana has the mental image of her holding a martini glass in one hand and a cigarette in the other. “As we all know, the biggest immediate risk facing Genoa is not so much the outbreak as the overreaction that will inevitably follow . . .”
While Alana agrees that mass panic will only compound the problems, she doubts it’s the plague’s most imminent threat. She feels the vibration of Nico’s cell phone against her leg.
“Excuse me,” he says, rising from the table.
Instinctively, she follows him.
Nico speaks into the phone at first in a whisper, but his voice rises sharply even before he clears the door. By the time Alana catches up with him in the hallway, his pupils are wide and he is barking into the receiver in a machine-gun staccato.
“What is it?” she asks, grabbing his arm.
Nico pulls the phone away from his ear. “Two new patients. One of them is a doctor. He’s one of my best friends.”
Chapter
Eleven
Today is the first day of February.
It is not for me to interpret the vagaries of fate, but I cannot help but wonder the same as the Archbishop did. Why have I been spared? To be left behind is more a burden than a mercy.
I write by candlelight now. I have only just now returned home from an arduous trek up to the San Giovanni Monastery. I had not anticipated the extent of the suffering I would encounter there.
The plain stone and brick buildings of the monastery stand humbly in relation to the palace of the Archbishop. But what the monastery lacks in color or charm is compensated for by the abbot himself. Don Marco greeted me at the doors with the affection of a man chancing upon a friend at a tavern, rather than welcoming a near-stranger to the plague-stricken commune.
I never doubted God would deliver you to us, Doctor Pasqua! he cried, as he patted me on the back.
He led me by the elbow through a doorway into the central room, the Warming House, where a fire was blazing even though it was still morning. The dreary chamber was nearly empty, the floors cold stone, the walls unadorned. A single long wooden table was the only furnishing. Our voices echoed as we spoke.
Where are the other monks? I asked.
Don Marco held up a helpless hand. We have delivered last rites to forty-one brothers already this month, he said. Almost half of our order. The others are either ill or caring for the ill or burying them. Even the scriptorium lies empty. We house one of the most enviable libraries in all of Genova, but there are no calligraphers free to continue the Lord’s work.
I had run out of words to comfort for such losses, so I held my tongue.
God has a plan for us all, though, does He not? Don Marco said as he summoned another smile. Where did you leave your horse?
When I told him that I had arrived on foot, he rushed over to a shelf on the wall. He pulled down a wineskin and removed a partial loaf of bread from a clay pot. You must be parched from the climb, he said. I am sure the Archbishop would not dare serve such slop to his lowest serf, let alone an honored guest, but I am afraid we have no better to offer.
Though I suspected the food was carefully rationed, I knew better than to insult my host by refusing. The wine was sour but drinkable and the bread nourishing, despite its saltiness. When I had finished the last bite, I asked him where they kept the infirm.
I wish we had time for a little spiritual and scientific discourse, Doctor. How I miss those days. But these times do not allow for such luxuries, do they?
I followed him outside and into a low-ceilinged building with a thatched roof. It was only then that I heard throaty moans and inhaled the stench of decay that so often heralded the afflicted.
We have converted the sleeping quarters of the novices into an infirmary, Don Marco said. After all, why not? All twelve of our novices have already departed this earthly world.
More than twenty wooden beds were occupied. Wet coughs and agonized groans filled the room. Three or four monks hurried from one bed to another, stopping to ladle water or kneeling to offer prayers.
The first man we came across was already dead. At initial glance, I thought the second, with his ghostly face, was as well. But despite his blackened fingers, which in my experience always portend an imminent demise, he was awake enough to look up at Don Marco with a weak smile. The abbot knelt at his bedside and prayed for him, bravely dabbing water on the monk’s forehead while whispering words of encouragement between his prayers.
It was not until we reached the fourth bed that I recognized a condition I could actually address. This monk’s armpits were painfully swollen with massive buboes. He lay before us silently, but the dried tears on his cheeks evidenced his agony. I hurriedly pulled my surgical instruments from my satchel. I stood as far back from the bed as I could as I lanced his swellings. Even still, I had to back away from the eruption of pus that greeted my knife.
And so it went all morning and into the afternoon. Two more brothers, including the one with the blackened fingers, died. I cannot claim to have made much, if any, difference for the fate of those cursed monks. But as we returned to the cloister, the abbot praised me as if I were a returning hero of war. He insisted on serving me more wine and bread. And I have to admit, it was hunger more than politeness that compelled me to accept this time.
As I was finishing my wine, I heard scratching somewhere below me. Two black rats emerged from under the table and scurried toward the wall, their long tails disappearing through a hole between the bricks.
It took a moment before I realized why the commonplace sight seemed so striking. I had seen more rats over the past month than I had in my entire life, but none of them had been alive. After all, this sickness was indiscriminate in its choice of victims. Livestock and animals were equally susceptible as people. Dead dogs, cats, and goats rotted on the streets of Genova until the stench became so unbearable that someone was forced to clear the carcasses. But dead rats outnumbered every other dead animal by at least ten to one.
What is it? Don Marco asked me.
Those rats, I said. They appear to be in good health.
It is true, good doctor, Don Marco said. In the initial weeks of this pestilence, we would find dead rats littered all over. However, in the past week I have seen robust rats scurrying about the premises. We have even caught the miserable vermin trying to feed off the remains of our brothers, he said with a shudder.
You no longer see rat carcasses? Only healthy rats?
He considered this for a moment. Yes. I suppose so. And it can only mean one thing, good doctor.
What is that?
For whatever reason, God has blessed these rats.
My chest pounded as if I were climbing the hill to the monastery again. It indeed meant something. However, I did not believe it had much to do with divine providence.
Chapter
Twelve
Alana grips the armrest of Nico’s SUV, as the vehicle races around another corner. The Ospedale San Martino appears ahead. The media vans are her first tip-off to the mayhem awaiting them.
Nico abandons the car on the opposite side of the street and rushes for the entrance. They elbow their way through reporters and camera crews crowding the main door. A security guard at the door checks Nico’s ID, before letting them enter.
Inside, voices are unusually low, faces grim. Another checkpoint has been established in front of the emergency room with a changing area and a makeshift decontamination zone walled off by freestanding dividers and sheets of plastic. Alana and Nico have to step into full PPE outfits before the security guard will allow them inside. Slipping the hood over her head, Alana experiences an uneasy flash of déjà vu.
