1996Explanatory Journalism

Inside an Outbreak

Epidemic Breeding Anger, Fear In Kikwit
By: 
Laurie Garrett
May 21, 1995

Kikwit, Zaire -- The young woman rocked, shell-shocked, on her porch, nursing her baby as she described the events that left her the sole caretaker of 16 children and her own teenage sister.

In April her niece had a Caesarean section at Kikwit General Hospital. Nine days later the niece was dead. A few days after that the niece's newborn died. Then her own mother, who had tended to the niece, came down with a piercing headache at the funeral. When she went to the local dispensary, a health-care worker examined her and determined that her uterus was out of place. He reached in to adjust it.

Within the week both her mother and the health-care worker were dead. The family members who had tended to the dying women and then helped prepare them for burial fell ill soon afterward, dying one after another: the woman's father, a sister, a second sister.

All suffered similar symptoms: high fevers, headaches, nausea, diarrhea, muscle pains, prolonged hiccoughing from spasms of the diaphragm and hemorrhagic bleeding. All, the woman would learn later, had died of Ebola, a mysterious virus that kills up to 90 percent of the people it infects.

Then, on a blazing hot early afternoon, as the woman rocked on her porch, several doctors approached. They needed her help to study the disease, they said, and they asked her for blood.

The response was quick and fearful.

"My sisters got needles in their arms. Afwaka," she said, using the local KiCongo word for "they died." "My mother got needles. Afwaka! My father -- afwaka . . .

"I will not!" she said. "No!"

Kikwit, a community of between 250,000 and 400,000 people that is really no more than a huge village without running water, a sewage system or electricity, is full of fear. It is the epicenter of an Ebola outbreak that health officials said yesterday has infected 155 people and killed 97. Yesterday's report includes 31 more infections and eight more deaths than the day before.

Most of the fear in Kikwit is directed at the hospital, where the gruesome illness with mysterious origins spread slowly, doctors believe, unnoticed for months until magnified by non-sterile practices.

It's a community full of anger, as well -- largely against journalists who have dropped in from around the world, intruding on funerals, photographing patients and using their names without permission.

It's a community full of heroism. Red Cross volunteers and others collect the dying and bury the dead. Before the international relief effort began, they didit without protective clothing, masks or gloves. Now, three volunteers have died of Ebola, and a fourth is struggling for his life in Kikwit General Hospital.

* * *

The day began with astonishingly loud claps of thunder, followed by intense tropical rain. Kikwit's dirt roads were rendered impassable mires, hindering efforts to control the city's Ebola epidemic.

When the rain stopped, the heat and humidity rose, baking the rutted roads into troughs interspersed with ponds. It is rough going for the multinational team of experts studying the mysterious microbe named Ebola, after a small Zairean river.

Nonetheless, they help gather the dead, draw blood samples from people and pet monkeys, treat the hemorrhaging patients and scour the hills of this enormous community in search of victims of the virus. The plan to end the outbreak is a fairly simple one: Isolate it by persuading residents not to touch the infected, and supplying health-care workers with infection-control equipment.

At day's end the leaders of the team of scientists and doctors are gathered in one of Kikwit's few restaurants, drinking cold Primus beer, chewing on tough goat meat spiced with hot peppers and ruminating over the day's discoveries.

It is known that the virus is spread by contact with blood and bodily fluids, but other routes of transmission are suspected. The World Health Organization's Dr. Guenael Rodier poses the question: If the virus is in a well or a glass of water, is it safe to use that water? Just how tough is this virus?

He recalls the first outbreak of Ebola, in Yambuku, Zaire, in 1976, when samples of the suspected virus were shipped to Paris inside glass tubes that floated at room temperature amid liquid nitrogen. Despite days under such conditions, the viruses inside those tubes remained deadly.

So, concludes Rodier, we must assume that the virus can thrive in water, especially here in the tropical heat. The leader of the team, Zaire's Dr. Tamfu Muyembe worries out loud about the panic that has driven the people away from the hospital at a time when a new wave of cases is expected. No one can give him an answer about how to address the panic.

There also is no answer to how and why the epidemic came to Kikwit.

The international team believes that the first infection probably occurred in January. Suspicion centers on a family in which six people died, suffering symptoms reminiscent of the Ebola outbreak in 1976.

Because no one is left alive from the devastated family, it is the job of Dr. Ali Khan, of the U.S. Centers for Disease Control and Prevention in Atlanta, to scour the family's neighborhood for clues.

The scientists are convinced that the deadly virus then wended its way through isolated groups in Kikwit for two more months, being recognized as an outbreak -- and even then not immediately -- only when it reached the hospital.

Doctors there were overwhelmed at the time battling another pathogen: shigella, an extremely contagious disease that causes bloody diarrhea. Among hospitalized patients, fatality rates can approach 20 percent even when treated with antibiotics.

Thus, scientists theorize, Ebola slipped in among the chaos unnoticed, its signature bleeding obscured by a companion disease. Evidence collected by the multinational team points to a man who was admitted to the hospital March 25 as the initial carrier. He died two days later.

By the first week of April, team members say, Kimfumu, a 36-year-old laboratory technician who was responsible for collecting blood samples from suspected shigella cases, fell ill. His belly was distended, and the physicians thought he had an intestinal perforation caused by typhus.

They operated twice, the scientists say. Unable to find the suspected perforation, the surgeons removed his inflamed appendix on April 10. When Kimfumu's stomach remained severely distended, they operated again.

This time when they opened the abdomen, they were horrified to see huge pools of blood -- uncontrollable hemorrhaging from every organ. Kimfumu died, and soon -- one after another -- members of the two surgical teams that had operated on the man also died. The dead included four anesthesiologists, four doctors, two Zairean nurses and two Italian nuns.

By May 5, when Muyembe arrived to begin his investigation into the deaths, the staff of Kikwit's hospital were in a panic. A virologist from the Universityof Kinshasa, Muyembe said he knew almost immediately that he was dealing with much more than a shigella outbreak.

"These people were given plenty of antibiotics," he recalls. "If it was shigella, they should have been well."

But the symptoms were horribly familiar to Muyembe. He had seen it before, in Yambuku in 1976, as a member of the team that investigated that outbreak. He made a list of the symptoms and mapped the connections between the hospital's cases. Muyembe could not escape the conclusion that his old nemesis -- Ebola -- had resurfaced in Zaire after a 19-year hiatus.

On May 7 Muyembe sent word to the World Health Organization in Geneva that Ebola was back, this time hundreds of miles to the south of the remote village area struck in 1976.

He also began mapping the outbreak with Kimfumu as Patient No. 1, with arrows pointing to the 12 people who got Ebola after treating him.

Within three days the world had heard the news, and the job of stopping the outbreak began. A team of experts was quickly gathered from the World Health Organization; the Zairean Ministry of Public Health; the Centers for Disease Control; the National Virology Institute of South Africa; Doctors Without Borders, in Amsterdam and in Brussels; and the Pasteur Institute in Paris.

Where Red Cross volunteers had to bury people in the past month without proper supplies, they now were given masks, plastic aprons, rubber boots, goggles, latex gloves and bright green gowns.

Local merchants have also now spent $10,000 to educate the people of Kikwit about how to protect themselves from Ebola. Don't touch anyone who is sick, the signs and pamphlets say. Don't wash bodies.

Nonetheless, the experts say it remains a difficult battle. When their advice conflicts with local customs, the customs often win out.

One woman was infected after helping a neighbor wash the body of his dead wife, a funeral ritual. The neighbor also got Ebola, according to Dr. David Heymann, of the World Health Organization, but he is one of the few who have survived.

Even so, when the second woman died her husband could not restrain himself from washing her body and preparing it for burial.

As the Red Cross truck bearing his wife's body disappeared over a hill, the man asked, in KiCongo, "Why did you spray my home with disinfectant? If the disinfectant can kill the virus, why don't you spray me?"

Medical student Titan Moloway explained that the spray could not kill viruses inside his body. And the man solemnly offered a vein on his forearm so medical technician Norbert Lafulu could withdrew a vial of blood.

Despite the advice, the dead and dying are becoming harder to find, according to investigators. Because they fear the hospital, many have fled Kikwit for nearby villages. In the local market in Kikwit, Kieshilamga, who sells smoked fish, says that she doesn't trust either the hospital or the doctors investigating the outbreak.

"Those persons were poisoned," she says of the Eebola fatalities. "I don't know who poisoned them, but this kind of disease came so suddenly. I pray most of the time for protection . . ."

* * *

While the people of Kikwit remain fearful of the hospital, they are angry with the journalists who have converged from throughout the world.

On Friday, WHO's Heymann and the CDC's Khan sat inside a dirt courtyard ringed by a cluster of wattle homes in Kikwit. They had come to talk to the widow of Kimfumu, the technician identified in the outbreak map as the first hospital-based infection.

But a man who identified himself as Kimfumu's brother-in-law turned angrily upon the scientists, demanding to know, "Why is all the world saying that Kimfumu started this epidemic? I heard it on the radio! On Voice of America and Radio France! Why are you putting the blame on Kimfumu?"

Heymann tried to explain that the report was inaccurate, but the family would not be mollified. Their loved one had been shamed internationally, they said, and they would cooperate no further.

"We asked these reporters not to use the patients' names, to respect their dignity and confidentiality," Heymann said angrily. "They all say `Okay,^ but then turn right around and do it."

Khan said the team posts the names of victims on the wall in the clinic so that the team can keep track of the patients, "but I have actually seen reporters come up and photograph the list. It's outrageous!"

* * *

As dusk set one night last week, a woman fell on a roadside in front of the abbey where a Catholic monsignor lives.

The neighbors gathered, speaking urgently to the ailing woman. She had come from Mosango, a village of 300 people to the south. Her husband had died of Ebola and the villagers abandoned her out of fear. She made her way to Kikwit in search of her brother-in-law. But she could not find his house and the taxi driver left her on the roadside.

A local official sent a child to alert the Red Cross, and as the green-suited crew arrived in their truck, some of the neighbors cried out in protest.

"Most of the time, when someone is taken from here to the hospital, he dies!" yelled a woman who wouldn't give her name. "Maybe they give him the disease in the hospital. Why are you taking her away? Leave her here. We will protect her. She will never return if you take her to the clinic."

The sick woman was so weak she could barely talk. As fireflies filled the blackened sky, the Red Cross workers lifted her into their truck and drove away.