Chapter Seven

The Akpro-Missérété Commune, Ouémé, the Republic of Benin

Eleven days ago

Dr. Panjay stepped out of the tent and pulled off her mask to reveal a face that was deeply troubled and deeply afraid. She peeled off her Latex gloves and her hands were shaking so badly she missed the biowaste bin on the first try. She heard the tent flap rustle and turned to see her colleague Dr. Smithwick come out into the dusty afternoon sunlight. Despite his sunburn, Smithwick was white as a ghost. He stood next to Panjay and removed his blood-smeared gloves and threw them, his mask and apron into the biowaste bin.

“You see why I asked you to come here? To see for yourself?” Panjay looked up into his face. “Thomas . . . what are we going to do?”

He shook his head. “I . . . don’t know. Aside from sending samples and our notes . . . I don’t know what we can do. This is beyond me, Rina.”

“Thanks for coming,” she said. “But . . . perhaps I should have prepared you better.”

Smithwick looked back at the big tent. With the flap closed he could not see the rows upon rows of cots, each one occupied by a farmer from the Ouémé River basin. Sixty-two people.

“Is this every case?” he asked.

She bit her lip and shook her head. “No. These are the healthiest cases.”

“I . . . don’t understand. . . .”

“Since I came here three weeks ago we’ve had three hundred people present with symptoms. Most of them have hemoglobin levels in the range of six to eight grams per deciliter with a high reticulocyte count. Some have demonstrated features of hyposplenism Howell-Jolly bodies.”

“You tested them all?”

“Yes . . . and five hundred other people chosen at random from the same towns or farms. Every single one of them showed signs of sickles hemoglobin. I tested their Hb S in sodium dithionite, and in every case the Hb had a turbid appearance.”

“Christ!”

“Not everyone has active symptoms, but when symptoms present we’re seeing a wide range of them. We’ve seen ischemia resulting in avascular necrosis; there have been cases of priapism and infarction of the penis in males of all ages; bacterial bone infections . . . the list is endless. Every symptom in the book. Even symptoms typically common in different strains are showing up in the same patients, including strokes due to vascular narrowing of blood vessels. There have been nineteen cases of cerebral infarction in children and widespread cerebral hemorrhaging in adults. And we’ve had increased occurrences of Streptococcus pneumoniae and Haemophilus influenzae in any patient who had undergone surgery. And not just splenectomies—I mean any surgery.”

“What are the primary causes of death?”

“Renal failure,” she said. “Across the board.”

Her words hit Smithwick like a series of punches. He staggered back and had to grab a slender tree for support.

“All of them?”

“Every one. Every person.”

“That’s not possible.” He licked his lips. “Do you have a map? Can you show me where the cases were reported?”

She nodded. “I knew you’d want to see it, so I have it already prepared.”

Rina Panjay led the way through the nearly deserted village. The only sound they heard was that of quiet weeping from people huddled around fresh graves in the cemetery and a single high keening moan of loss echoing from a child’s bedroom where a desolated mother sat clutching a doll to her chest as she rocked back and forth. Panjay’s eyes were red from all the tears she had wept for this village over the last few weeks. She felt used, destroyed, totally helpless.

They entered the small World Health Organization blockhouse that normally served as the hospital for this rural corner of Ouémé. There were no patients in the hospital now—everyone had been moved to the big tent that had been erected in the middle of a field far from town and well away from the water supply.

There was a large map of the district that was littered with hundreds of colored pins tacked to the wall. The rest of that wall and some of the next was covered floor to ceiling with printouts of digital photographs of the victims. These, too, were color coded by pins. Victims without active symptoms had white pins. Victims with active symptoms had red pins. The dead were marked with black pins. Panjay pointed to a spot on the map. “This is where the first case was reported. The next was here, the next here.” She tapped the pins as she spoke and Smithwick’s face, already ashen, went paler still.

“No . . . ,” he said.

Panjay lowered her hand. The pins on the map said all that was necessary. The pattern was clear. A first-year medical student could understand the implications, though to a seasoned WHO epidemiologist like Thomas Smithwick it was so clear that it screamed at him.

“This is impossible, Rina,” he said. “What you’re describing can’t be sickle-cell. You must have made a mistake. The samples must have been contaminated.”

She gave a weary shake of her head. “No. I had the results checked at three different labs. That’s why I called you. I don’t know what to do . . . this isn’t something I’m trained for.”

It was true, Rina Sanjay was an excellent young doctor, fresh from her internship at UCLA Medical Center and a brief stint as an ER doctor in Philadelphia’s Northeastern Hospital. She could do anything from deliver a baby, to diagnose HIV, to perform minor surgeries for wound repair. But all of the tests said the same thing: sickle-cell anemia. A genetic disorder.

Smithwick on the other hand had spent twenty-six years with the World Health Organization. He had been in the trenches in the fight against the spread of HIV throughout Africa. He’d worked on two of the most recent Ebola outbreaks in Uganda and the Democratic Republic of Congo. In any other circumstance he was the wrong specialist to call in for something like this.

“What you’re describing is impossible,” he insisted. “Sickle-cell is not a communicable disease. It’s strictly genetic. But this . . . this . . .” He waved his hands at the map. “This map suggests the spread of a communicable disease.”

Rina Panjay said nothing.

“It’s impossible,” Smithwick said again. “Genetic diseases are not communicable.”

“Could it have mutated?”

“So fast? And to this degree of virulence?” He shook his head. “No . . . there’s just no way that could happen. Not in ten thousand generations of mutation.”

“Then how could it happen?” she asked.

The air between them crackled with tension as Smithwick fought against the words that were forming on his tongue. The answer was as simple as it was preposterous. As simple as it was grotesque.

Smithwick said, “It’s theoretically possible to do it. Deliberately. In a lab. Gene therapy and some host, perhaps a virus . . . but there would be no point. Gene therapy has a purpose, a goal. This doesn’t. This is . . .” He fished for a word.

“Evil?” she suggested.

He was a long time answering, then nodded. “If this is something someone has done . . . then it could only have been created for one purpose. To do harm. To intentionally do harm.”

Dr. Panjay looked at the map and then her eyes moved across the hundreds of color photographs pinned to the wall. Many of the pictures were of people she knew. Over fifty were from this village. Everyone in the village she had tested had come up positive for this new strain of sickle-cell. Every single person.

“We have to inform WHO,” Panjay said. “We have to warn them—”

“No,” Smithwick interrupted. “We have to warn everyone.”

He stared at the pins.

“Everyone,” he repeated softly, but in his heart he was terrified that they were already too late. Far too late.