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Last Updated

26 Feb 2003

Source: Esquire 139 (3), 214-222, March 2003.

What Ever Happened to Anthrax?

First of Two Parts (click here for second part)

In October 20O1, a sixty-three-year old man staggered into a Florida hospital with a case of what appeared to be bacterial meningitis. It wasnít. It was our nationís first case of inhalational anthrax in twenty-five years, and Bob Stevens was our first victim of bioterror. The story of his almost miraculous diagnosis reveals just how lose America came to utter disaster.


Bob Stevens (case 5) is half dead by the time Larry Bush gets to him. He's isolated in room 27, a cramped rectangle just off the emergency room at JFK Medical Center in Atlantis, Florida, a bedroom town south of West Palm Beach. A ventilator is pushing air into his mushy lungs, and there's a bandage on his back covering a hole where a needle siphoned out a few milliliters of his spinal fluid. He's been in the hospital for six hours.

Bob Stevens is sixty-three years old and, except for the stent propping open one of his coronary arteries, in decent health. Or was, anyway. He's going downhill fast.

He showed up with his wife, Maureen, just after two o'clock that morning, Tuesday, October 2, 2001, fevered and barely coherent but still able to walk. He'd been achy for a couple days, lethargic, running a mild temperature. Nothing serious, nothing that kept him from driving all the way home from North Carolina the day before, Charlotte to Lantana, ten hours if he didn't stop, which he didn't. He was home by five, in bed by eight, with a temperature of 101. Five hours after that, around one, he was vomiting in the bathroom, so Maureen packed him into the car and drove him to JFK. He was there for a few hours before having a massive seizure, which is why he's now in room 27 with a machine doing his breathing for him.

The night-shift doctors didn't know what was wrong with him, not exactly. His chest X ray was funky, showing a murky cloud between his lungs and swelling in the tissues called the mediastinum. His spinal fluid was a mess, too. In a healthy man, it's clear and clean like water. Bob's was milky white, polluted, angry-looking. The preliminary diagnosis was some kind of aggressive meningitis.

That's why Larry Bush is called in. He's the chief of staff at JFK and a specialist in infectious diseases. A bug doctor. Which is like being a hunter, really, tracking microscopic trophies, bacteria and viruses, studying them, deciphering their defenses and their weaknesses, figuring out how to kill them. Bob Stevens is in need of a bug hunter.

Larry pads into the hospital shortly before eight o'clock, a slender man with an unruly fringe of wiry hair, a graying goatee, and a tense and buoyant energy that makes him seem younger than his forty-nine years. He checks on Bob, reviews his vitals, eyeballs the vial of cloudy spinal fluid. He suspects bacterial meningitis, too. Serious, yes, but treatable and not uncommon: JFK gets a couple cases a month.

He leaves the ER and heads down the long blue hallway leading to the lab, where a droplet of Bob's spinal fluid has already been smeared on a slide and stained with a chemical that highlights bacteria. Larry perches on a stool in front of an Olympus BH-2 microscope, pushes the slide into place, and adjusts the lens to magnify the view one thousand times. He leans over, focuses through dual eyepieces.

He blinks. Looks again. Blinks again.

Infection is swarming through Bob Stevens. The slide is overrun with bacteria. But it's the shape of the bacteria that scares Larry Bush. They're long and slender, like sausages stained purple, and linked together in jumbled chains-the distinctive profile of the Bacillus genus. Except bacilli shouldn't be floating in anyone's spinal fluid. Most types of bacilli-there are a few dozen are harmless, neither hardy nor aggressive enough to cause serious infection. Usually when bacillus germs show up on a slide it's because a lab tech didn't scrub up properly and a few benign bacteria sloughed off his hands, contaminating the sample. Even then, there's only a few of them.

But Larry's never seen anything like this before. Fourteen years at JFK, four thousand consultations each year in the ER alone never once has a similar colony of bacilli glowed under his microscope. In his mind, then, he starts cataloging the suspects, the handful of harmful bacillus germs that might have taken root in Bob's body and made him sick. It could be Bacillus subtilis, but that is usually found in people with crippled immune systems, worn down by AIDS or chemotherapy. Bacillus cereus is another possibility, but that gets into the body only through direct trauma say, on a germy stick shoved into an eyeball.

But Bob doesn't have any gaping wounds, and his immune system is fine. Had been, anyway.

Larry looks through the lens again. The bacteria are just lying there, inert, like miniature boxcars toppled off invisible rails. Subtilis and cereus squirm and crawl and swim. These aren't moving at all. And that's when Larry realizes there is only one potential suspect left: Bacillus anthracis. It's the only thing that fits. The shape, the way it behaves on the slide, the damage it's done to Bob. Anthrax. Bob Stevens has fucking anthrax.

The thing is, nobody gets inhalational anthrax, not anymore, not for twenty-five years. In all of the twentieth century, only eighteen Americans came down with it. And most of them worked in mills with animal hides, breathing in the invisible spores that floated from the remnants of infected goats and sheep; that's why they called it woolsorter's disease. Bob Stevens isn't a woolsorter. He edits photographs at a tabloid newspaper in an office building in Boca Raton.

Larry is sure of what he's seeing, though. The patient is infected with anthrax, and the odds that he was infected with it naturally are so improbable as to be impossible. There's only one way Larry can explain it, then: Someone deliberately infected him. Bob is a victim of a biological attack.

An anthrax attack has never happened before. But Larry knows it's not unthinkable, not when there's a mountain of rubble still smoldering where the World Trade Center stood just three weeks ago. Hell, he probably knows about the field teams roaming all over lower Manhattan, trying to catch a whiff of germs or gases the terrorists might spray on the ruins to poison all those rescue workers and take out another few thousand people. If not New York in September, why not south Florida in October? A few of the September 11 hijackers had lived for a time near Atlantis. They'd even asked about crop dusters at a little municipal airfield not far from Lantana. It was possible.

A lot of very smart people, epidemiologists and generals and civilian-defense analysts, had been worrying openly about a biological attack for years. When one came-not if it came, but when they said it would be apocalyptic, a medieval cataclysm. The terrorists would blow the germs through the subway tunnels or dump them into the vents at the Mall of America or mist them from a plane flying low over Santa Monica Boulevard. Maybe they'd use plague or maybe they'd use tularemia, but they'd just as likely use anthrax. All the bad guys have anthrax. A lot of the good guys, too. The Soviets used to mill it by the ton, and the Iraqis are suspected of having enough to take out the entire Arabian peninsula. At last count, as many as seventeen countries were cultivating it in one way or another. And that's just the weapons-grade stock, the stuff with spores ground to their tiniest and deadliest. The lesser grades? There are hundreds of research labs around the world with vials of unrefined anthrax strains stored in flimsy cabinets.

Larry had kept up with all the reports, had read all the articles in the medical journals about how anthrax was supposed to behave if used as a weapon, how it would spread, the damage it would wreak. At first, no one would even notice that there'd been an attack. No one would smell it or taste it or feel it, not even while they were sucking spores deep into their lungs, into the spongy lining where the bacteria would start worming their way to the lymph nodes. After a week or so, a few dozen casualties would stumble into the ER, fevered and babbling, their insides dissolving into goo. Once the doctors figured out what was wrong with them, it'd be too late. And then more patients would come: The feds estimated that a hundred kilograms of premium anthrax spores released upwind of Washington, D. C., could kill up to three million people in a span of six weeks.

It would be an act of war, of course, or the work of a sophisticated pack of terrorists, because anthrax is not a viable weapon for the lone nut, not like mixing fuel oil and fertilizer in the back of a Ryder truck. Getting the germs from their natural state-dormant spores are found mainly on prairies and grazing lands-to a poison cloud takes considerable technical proficiency (as well as an up-to-date vaccine). Nor is it useful for surgical strikes; an invisible mist of anthrax is almost impossible to contain once it's released. It would happen like that, huge and awful and all at once, because there is no reason for it not to.

If this is an attack, in other words, then the germs in Bob should also be germinating in a few thousand other people by now. Larry's thinking, if this stuff has been aerosolized, it could take out a quarter million people. JFK can't treat that many people. Florida can't treat that many people, not when they get this sick this fast. Bob was up on his feet seven hours ago; now he's rasping through a plastic tube. They'll die before we can get them into a bed, he thinks. Even if there's only a hundred victims, we can't treat them-we don't have a hundred ventilators. They'll die.

But there aren't a hundred other victims. In fact, as far as Larry knows, there aren't any other victims in Palm Beach County. Not yet. Which doesn't make sense, not according to the models.

Larry walks out of the lab. He tells the head nurse to move Bob to the intensive-care unit immediately because Bob's so sick and because there's less traffic there, less chance for an orderly to overhear a stray comment, repeat it, and throw the whole hospital into a panic. Then he leaves, marches across the parking lot toward his office in the building on the other side. On the way, he sees one of his colleagues, Barry Abrams.

"I've got a guy in the ER," he tells Abrams, "and I think he has anthrax." He hears himself say this and shakes his head. "No. I'm pretty sure he has anthrax." The two doctors stare at each other. "Do you know what that means?" Larry asks.

They say it together: "Bioterror."

It doesn't make any sense, and there isn't any other answer.

There is a theorem, Occam's razor, that doctors rely on when diagnosing patients. Distilled from the fourteenth-century philosophical writings of William of Occam, it holds that the simplest answer is usually the correct answer. For example: Just as a woman with a runny nose and a cough probably has a cold, a man with bacterial meningitis is probably infected with a germ the average infectious-disease doctor has seen in his professional lifetime.

Larry Bush is edging backward now along the razor. And he has to move fast. It's nine o'clock in the morning, he's been treating Bob Stevens for barely an hour, and already he's worried about the implications. The word keeps strobing in his head: implications. He can't just announce that Bob has anthrax, that Palm Beach County is under biological attack. There'll be panic in the streets.

And what if he's wrong?

But what if he's right? How long can he wait? Hours, maybe a day. He suspects the exposure has been limited because the odds of Bob, already that ill, being the only one to stumble into the ER are too long to matter. But there will be others, he guesses. Even if the germs had been sprinkled on Bob's front lawn, a light breeze would be enough to lift them from the grass and blow them down the street, across yards, through windows, and into lungs.

Larry pulls aside a technician in the hospital's lab and tells him what he suspects. He orders tests for subtilis and cereus so he can rule those out. He has to wait more than four hours, until 1:30, for the results. They're both negative. Even then, he can't say the germs are anthrax. The implications. Besides, JFK doesn't have the supplies to test for Bacillus anthracis. Hardly any hospitals do. Who stocks tests that haven't been needed in a quarter century?

Larry sees that the culture is sent to the state lab in Jacksonville. Overnight delivery, a full day to run the tests -- almost thirty hours before he will have a final answer. Too long to keep his suspicions secret, too long to risk someone else getting sick.

Just after three, he closes his office door and calls Jean Malecki, the director of public health in Palm Beach County.

"Is your door closed?" Larry asks her. His voice is low, not much above a whisper. It has an echo of his Philadelphia roots. "I've got a guy in the ICU, and I think he has anthrax," he says. Anthrax? Jean's just spent that very afternoon across the street from her office at a seminar on biological and chemical weapons where one guy -- no shit -- who was supposed to be an expert got up and said no terrorist would use anthrax. It's too complicated, he said. Too dangerous. And now, right now, this same afternoon, Larry thinks he's got a patient with it? C'mon. Is this a joke?

"Larry..." she says. She's known him for more than a decade, respects him, believes he's good at what he does. She's never known him to be an alarmist, but she doesn't know what to say. "Larry, you're a very talented infectious-disease specialist...... She doesn't finish the sentence. My God, she's thinking. What do we even look for?

Penicillin kills it. The most primitive antibiotic, the first one ever discovered, destroys the germs cultured from Bob's spinal fluid. By late Tuesday, Larry has discovered that other antibiotics -- doxycycline, amoxicillin work against the bacteria, too. It's probably too late for Bob, though. He's been unconscious for ten hours already. There are millions of bugs swimming through his system, too many for drugs to neutralize.

But Larry's surprised, and more than a little relieved, that antibiotics are proving at all effective, because weapons-grade anthrax would very likely be engineered to resist them for maximum killing power. (Why go through the trouble of poisoning people if a handful of common pills will keep the enemy in fighting shape?) Still, even anthrax that hasn't been tweaked in the lab is an exceptionally lethal bacteria. It mostly infects animals-cows and sheep and other ruminants that graze through grasslands where the dormant bacteria are curled up in microscopic spores, like hard little cocoons. What happens is, every so often, a few thousand spores get chewed loose from the soil and swallowed or inhaled. Once inside an animal's body, the germs wake up, multiply, and begin to feed. At the same time, they excrete one toxin that destroys individual cells and another that causes the body's soft tissues to swell and eventually liquefy, collapsing into mush.

That hardly ever happens to humans, who typically don't graze on prairies. Occasionally, though, a few spores will sneak in through a cut on a rancher's hand or a scrape on a gardener's wrist, leading to a cutaneous infection. That isn't particularly serious, though, just an ugly lesion that is generally cleared up by a course of antibiotics. In any case, it doesn't happen often: Between 1944 and 1994, only 224 cases of cutaneous anthrax were diagnosed in the United States.

The worst form of anthrax, the deadliest version, is inhalational anthrax. It is also exceedingly rare: More people get bubonic plague every year than have contracted inhalational anthrax in the past twenty years. That's because spores tend to clump together, attracted by a static charge, the same way dust clings to a television screen. A knot of, say, twenty spores is big enough to be trapped by nose hairs or blocked by cilia lining the airways, which prevents them from burrowing into the tiniest crevices of the lungs. Which is also why making a weapon out of anthrax is so difficult: The dormant germs, to be effective killers, have to be milled down to a micron or so-a human hair is about seventy-five microns wide-and then mixed with an antistatic agent to keep them separated.

Bob Stevens has inhalational anthrax. Larry doesn't need the official test results to know this. He's looking at the goddamn germs. He also knows there's no chance Bob contracted this accidentally; the last time a cow got anthrax in south Florida was 1951.

But there are no mass casualties. The germs can be killed with common drugs. The nation's first anthrax attack is not going according to plan.

End of First of Two Parts (click here for second part)