CHAPTER 1

St. Raphael's was an old Catholic hospital, struggling to maintain its independence in the face of overtures--friendly and outright aggressive--from Johns Hopkins and the University of Maryland. The hospital sat in the middle of a decayed neighborhood in the southwestern quadrant of the city, surrounded to the north and west by housing projects and to the south and east by a mix of old factories and abandoned row homes. The hospital served the needy in the immediate area, but extended its reach to the working-class neighborhoods of Pigtown and Locust Point. The last I heard, it was hemorrhaging money and talks with Hopkins and Maryland had started up again, this time at St. Raphe's behest. The former belle at the ball, now trying to dance with anyone who'd have her. Rumor had it the powers that be--admin at St. Raphe's, the Catholic archdiocese, the city, Hopkins, U of M--were just going to shutter the old girl. As the dirty pile of bricks, streaked black and dotted with a few forlorn statues of St. Raphael, came into view, I thought a mercy killing might not be the worst thing.

Still, there was a soft spot in my heart for the place. I'd just spent two weeks at St. Raphe's setting up a program to identify exactly the kinds of things that seemed to be happening. Outbreaks. Bioterror attacks. Bad things. St. Raphe's, in other words, needed me. Not like Hopkins, who basically taught my employers, the Epidemic Intelligence Service at CDC, how to play their game. If every employee at CDC were suddenly to die or, worse, to take a job in the private sector, Hopkins probably felt it could rebuild the Centers from scratch. No, St. Raphael's was a third-tier hospital in a city dominated by some of the best medicine in the world. My job was to get this old gal up to snuff.

Okay, my job. I am an officer in the Epidemic Intelligence Service, a branch of the Centers for Disease Control and Prevention. Apropos of my duties--to conduct surveillance for and investigations of outbreaks of disease--the title of officer is a fitting one. The cop jargon has been with us for a long time. Medical detectives was often used to describe officers in the service by those on the outside and on the inside, though the term long ago fell out of use, perhaps because it sounded a little too self-aggrandizing at the same time it sounded a little too trite. Anyway, that's what we do. We look for and hunt down diseases.

As with many things--fashion, say, or diet plans--there is some circularity to the history of the EIS. Originally conceived at the start of the Korean War as an early-warning system for biological attack, the EIS has spent decades searching for things to do. And it's done a pretty good job of finding them. The Service was instrumental in restoring public confidence after a polio vaccine scare in the fifties, it helped erase smallpox from the world, in the late nineties and early '00s it tracked down and set up surveillance for West Nile virus. And now the country is back to freaking out about bioterrorism. Which is why I was in Baltimore, helping to patch a hole in the country's disease-surveillance net. Normally, an old hospital wouldn't merit much attention, but St. Raphe's proximity to the nation's capital scared the public health gods, who wanted to ensure that any outbreak in the area was identified quickly. So, they sent me to set up a surveillance program.

Me. I'm part of the Special Pathogens Branch, which is in the Division of Viral and Rickettsial Diseases, which, in turn, is part of the National Center for Infectious Diseases, one of the Centers in the Centers for Disease C & P. My knowledge doesn't go too much deeper than that. Though I could spit out to you molecular biology of the family Arenaviridae, I couldn't sketch the organizational chart of the CDC. I leave that to the brilliant bureaucrats and technocrats in Georgia and Washington. If there was a Nobel for institutional complexity, these guys would lock it up year after year.

I pulled my car into a no-parking zone near the Emergency Department and slapped the Baltimore City Health Department placard on the dashboard. I fished in the glove compartment and found my old CDC placard and put that out, too. Outbreak or no outbreak, the last thing I wanted to deal with was a towed car.

I ran through the automatic doors to the Emergency Department, pulling my ID around my neck as I went. The place was oddly serene; it was, after all, early morning, July, and a weekday. That was a good thing. Although Verlach was on edge, it seemed word hadn't filtered out to the rest of the hospital or, God forbid, the press. The past few years--the anthrax fiasco, SARS--had taught the public health world the finer points of a 24/7 media with an insatiable appetite for the new, new thing.

There was a beige phone on the wall behind the nurses' station. I grabbed it, pounded in the pager number for the hospital epidemiologist, and waited. Two minutes later, the phone rang. I picked it up before the first ring ended.

"Dr. Madison, it's Nathaniel McCormick. I'm in the ED," I said.

The voice that came over the phone was faint, muted. "And I'm up on M-2. What the hell are you doing down there?"

CHAPTER 2

M-2 was a single hallway flanked by double-occupancy rooms. The white linoleum floor was long ago scuffed to gray, the beige walls streaked with a grime that never quite vanished, despite the best efforts of housekeeping. It was the mirror image of M-1, the medicine unit directly below it, except that the end of M-2 was capped by a set of metal double doors.

A laser-printed sign was taped to the doors: ISOLATION AREA: Contact Precautions MANDATORY. Authorized Personnel ONLY. Questions? Call Bioterror/Outbreak Preparedness at x 2134. Thank you!

Now, no one's ever accused me of being understated, but I thought introducing a loaded word like bioterror might be a wee bit alarmist.

The isolation unit was split into two areas. I was in the first, a small vestibule with two sinks, a big red biohazard trash bag, and trays of gowns, goggles, gloves, and shoe covers. Three opened boxes of half-mask, negative-pressure respirators sat on a rolling cart. The respirators filtered down to five microns, about the size of, say, hantavirus. I was glad to see they were sufficiently worried.

This type of arrangement--a small, cordoned section of the hospital--was a holdover from the bad old days of tuberculosis. Not all hospitals had them anymore; most places just isolated the sick in private hospital rooms. But here was a short hallway flanked by four rooms, two on each side, cut off from the rest of the building, dedicated to keeping the infectious and infirm from the rest of us. A good little quarantine area.

After suiting up and finding my size respirator, I opened another set of doors at the back of the room. As the door cracked, I could hear a rush of air, felt a suck against the disposable gown. The negative-pressure system--pressure greater outside than inside, to prevent small particles from being blown into the rest of the hospital--was working. The air would be passed through a filter, then blown outdoors.

I made sure the respirator was fast against my face; then I pushed open the door and walked inside.

Three figures, looking like aliens in their protective getup, were talking in the middle of the hallway. Besides the people, there was nothing here but a crash cart, a large biohazard waste can, and a table with a fax machine, paper, and pens. The crash cart was filled with drugs, paraphernalia for placing a central line, basically anything we'd need if a patient's heart stopped or, in medical parlance, if they "crashed." The fax was directly connected to another machine at the nurses' station outside the biocontainment zone. Notes, orders, and the like would be sent from there to the other fax. It's how we planned to get around carting contaminated medical records back and forth into the hospital. St. Raphe's, like many places, was still in the dark ages of paper records.

Despite their masks, I recognized the female Dr. Madison and Dr. Verlach, who was black. The third man, an older white guy, I didn't recognize. I stepped up to the group, which made sort of an amoeboid shift to accommodate me.

"Antibodies?" Verlach asked, his speech raspy and tinny through the respirator.

"Not yet. Nothing specific," Dr. Madison said. "No idea what it is. . . ."

Finally, the three looked at me. Verlach said, "Dr. McCormick, you know Jean Madison. This is Gary Hammil--" He pointed at the man I didn't know. "He's the new Chief of Infectious Diseases at St. Raphael's."

Ah. The new Chief of ID. St. Raphe's had been casting around for someone for months; they must have netted Dr. Hammil in the past few days. Nice of them to tell me.

I looked at Hammil. "Nothing like diving in headfirst."

"Especially when the pool has no water," he said. We both forced a laugh.

"Dr. McCormick is on loan to us from CDC," Verlach explained.

"Okay, thanks for the introductions," Jean Madison said, annoyed. Then, to me, "Tissue, blood, saliva have all gone to the labs here."

"Here?" I asked.

"Baltimore City."

I looked at Verlach. He said, "Fastest turnaround. We sent samples to the state lab, too."

Hammil asked, "What do they have at the city labs?"

Verlach looked at the floor. "Um, we don't have much, mostly run-of-the-mill. But state is pretty stocked. Tests for the filoviruses, Marburg and Ebola. I think they have Lassa, Rift Valley, Rocky Mountain spotted fever, Q fever. More. They don't have everything, but they have a lot, actually."

"Well, CDC is there if you need us," I said. CDC had resources--modes of analysis, genetic libraries of pathogens--that far outstripped those of Baltimore City or Maryland State. We had, in fact, the largest repository of disease-specific tests in the world at our headquarters in Atlanta. We also had the largest repository of actual bugs. Not a place to take your kids when they're in the oral stage.

Madison spoke quickly. "Thank you, but I think we can handle this here."

Gary Hammil said, "Jean--"

"We have access to the state labs," she interrupted. "We don't need to call in the federal government."

A word about CDC's relationship with everybody else in medicine and public health: our jurisdiction is everywhere and nowhere. Really. We intervene only at the request of individual counties and states. If there's no request, CDC stays out of it. And though there are a million reasons why someone would want to ask for help from Atlanta, there are a million reasons why they wouldn't, most of them having to do with control.

During my training in Atlanta, they drummed into us, over and over again, the finer points of dealing with the locals. In general, we try to tread very softly. It's not something I'm particularly good at. In my evaluations over the previous year, "professional relations" was an area that consistently contained the phrase needs improvement.

Hammil looked at me. "Dr. McCormick, we appreciate your offer of support."

I nodded. I nod when I'm not exactly sure what to say.

Madison sighed. "Well, it looks like we have the lab situation worked out, for the time being, anyway. We'll use state." She turned to Verlach. "Baltimore City will head the outbreak investigation?"

"Yes," Verlach said. "I already spoke to the commissioner. We'll call state for more hands if we need to. Since Dr. McCormick is already here and familiar with the city, I'm going to ask that he stay on for the investigation."

Silence.

"I'd be happy to help," I said finally.

"I thought we agreed to rely on state," Dr. Madison said.

"For the labs, Jean, not for the investigation itself. Dr. McCormick is more familiar with this situation than--"

"Having CDC involved is going to signal the press--"

"He's already here, so we can downplay the request. Besides, not having him on board would seem like an oversight."

"I want to emphasize," I said, "CDC is here to help at your request. Just as it was with setting up the surveillance program, we can be as much or as little a presence as you want. The investigation and outbreak control will all be locally led, as well as contacts with the press. We'd also be happy to provide you with clinical expertise."

There was a long silence, and I knew I had just stepped into it somehow. Jean Madison--the Consistently Aggrieved--finally blew. "Oh, come off it. Clinical expertise?"

I stammered, "I'm merely offering assistance if you should need--"

"--if we should need clinical expertise. I know. Thank God you're there for us."

I looked at my shoes, covered in light blue paper booties. I sighed.

Jean Madison let out a sharp little laugh. "What do you think we do here, Dr. McCormick?"

"I--"

"We have some of the finest staff in the city to--"

"Jean--" Dr. Hammil said.

"--care for these women."

"I'm not commenting on the in-house expertise," I began.

"Of course you are! You seem to think you're in some backwoods clinic. Surprise, surprise, we have seen our share of sick people, and they do get better."

"I wanted you to know there are resources available to--"

"Thanks for your input, Doctor. We'll take it under advisement." With that, she turned to the door. Before opening it, however, she turned back. "I'm calling a staff meeting, gentlemen, in ten minutes. Dr. McCormick, since you seem to have expertise we don't possess in-house, I'd like you to present your differential for these women."

"But I haven't even seen the--"

She was already out the door.

Another door opened as a nurse, dressed in her moon suit, exited one of the patient's rooms. She said hello to us, then disappeared into another room. A hospital, even an isolation ward, is a place of constant activity. Constant interruption, constant opening and closing of doors. Privacy for patients as well as for their caretakers is an alien concept.

After the nurse was gone, Hammil said, "How old are you, Dr. McCormick?"

"What? I'm thirty-three."

He nodded. "I guess that explains a lot. Grow up." He caught Verlach's eye, turned, and followed Jean Madison into the vestibule. The door closed with a hiss.
 

Excerpted from ISOLATION WARD © Copyright 2011 by Joshua Spanogle. Reprinted with permission by Delacorte Press, a division of Random House, Inc. All rights reserved.