The WHO maintained a stockpile of millions of doses of smallpox vaccine in freezers in a building in downtown Geneva they called the Gare Frigorifique—the Refrigeration Station. Much of the vaccine in the freezers had been donated to the Smallpox Eradication Program by the Soviet Union. The traditional vaccine for smallpox is a live virus called vaccinia, which is a poxvirus that is closely related to smallpox. Live vaccinia infects people, but it does not make most people very sick, though some have bad reactions to it, and a tiny fraction of them can become extremely sick and can die.
A staff member from the Gare Frigorifique drove a couple of cardboard boxes full of glass ampules of the Russian vaccine to the Geneva airport—one hundred thousand doses took up almost no space. The vaccine did not need to be kept frozen, because after it was thawed it would remain potent for weeks. Thousands of smallpox-vaccination needles were also shipped to Germany. They were a special type of forked needle called a bifurcated needle, which has twin prongs.
As quickly as possible, the German health authorities organized a mass vaccination for smallpox all around the Meschede area. This was known as a ring-vaccination containment. The smallpox doctors intended to encircle Peter Los and his contacts with a firewall of immunized people, so that the tiny blaze of variola at the center would not find any more human tinder and would not roar to life in its host species.
Meschede came to a halt. People left their jobs and homes, and lined up at schools to be vaccinated, bringing their children with them. A fear of pox—a
Pocken-angst—
spread across Germany faster than the virus. People who drove in cars with license plates from Meschede found that gas stations wouldn’t serve them, nor would restaurants. Meschede had become a city of pox.
Nurses and doctors gave out the vaccine. A person who was working as a vaccinator would stand by the line of people, holding a glass ampule of the vaccine and a small plastic holder full of bifurcated needles. The vaccinator would break the neck of the ampule and shake a needle out of the holder. She would dip the needle into the vaccine and then jab it into a person’s upper arm about fifteen times, making bloody pricks. You could have blood running down your arm if the vaccination was done correctly, for the bifurcated needle had to break the skin thoroughly. Each glass ampule was good for at least twenty vaccinations. As people passed in the line, a vaccinator could do hundreds of vaccinations in an hour. Each needle was put into a container after it had been used on one person. At the end of the day, all the needles were boiled and sterilized to be used again the next day.
Each successfully vaccinated person became infected with vaccinia. They developed a single pustule on the upper arm at the site of the vaccination. The pustule was an ugly blister that leaked pus, and oozed and crusted, and many people felt woozy and a little feverish for a couple of days afterward, for vaccinia was replicating in their skin, and it is not a very nice virus. Meanwhile, their immune systems went into states of screaming alarm. Vaccinia and smallpox are so much alike that our immune systems have trouble telling them apart. Within days, a vaccinated person’s resistance to smallpox begins to rise. Today, many adults over age thirty have a scar on their upper arm, which is the pockmark left by the pustule of a smallpox vaccination that they received in childhood, and some adults can remember how much the pustule hurt. Unfortunately, the immune system’s “memory” of the vaccinia infection fades, and the vaccination begins to wear off after about five years. Today, almost everyone who was vaccinated against smallpox in childhood has lost much or all of their immunity to it.
The traditional smallpox vaccine is thought to offer protective power up to four days after a person has inhaled the virus. It is like the rabies vaccine: if you are bitten by a mad dog, you can get the rabies vaccine, and you’ll probably be okay. Similarly, if someone near you gets smallpox and you can get the vaccine right away, you’ll have a better chance of escaping infection, or if you do catch smallpox, you’ll have a better chance of survival. But the vaccine is useless if given more than four to five days after exposure to the virus, because by then the virus will have amplified itself in the body past the point at which the immune system can kick in fast enough to stop it. The doctors had started vaccinating people at St. Walberga Hospital five and six days after Peter Los had been admitted. They were closing the barn door just after the horse had gone.
The incubation period of smallpox virus is eleven to fourteen days, and it hardly varies much from person to person. Variola operates on a strict timetable as it amplifies itself inside a human being.
The Student Nurse
JANUARY 22, 1970
ELEVEN DAYS AFTER
Peter Los arrived at St. Walberga Hospital, a young woman who had been sleeping on a cot in one of the bathrooms woke up with a backache. She was a nursing student, seventeen years old, and I will call her Barbara Birke. She was small, slender, and dark haired, with pale skin and delicate features. She was a quiet person whom nobody knew much about, for she had been working at the hospital for only two weeks, and had been living in the nursing school dormitory while she received her training. The previous year, Barbara had been a kitchen helper in a Catholic hospital in Duisburg, where she had converted to the Catholic faith (her family was Protestant), and she had set her sights on becoming a nurse. She had spent Christmas with her family and had told her parents that she intended to become a nun, but she wanted to finish nursing school before she made up her mind. The Sisters of Mercy had reserved a place for her in the cloister.
Barbara Birke had never seen Los’s face. She always worked on the third floor of the hospital, and she had been tending to a sick elderly man in Room 352, near the head of the stairwell that went down through the middle of the building. She had received both the German vaccine and the WHO vaccine a few days earlier.
Birke told the doctors that she wasn’t feeling well, and they saw that she had a slight temperature. They immediately gave her an intravenous dose of blood serum taken from a person who was immune to smallpox. Smallpox-immune serum is blood without red blood cells—a golden liquid—and it is full of antibodies that fight the virus. They put Birke inside a plastic bag, and she lay in the bag while an ambulance carried her on the winding road to Wimbern and through the fence to the isolation unit.
Barbara Birke developed a worried, anxious look, while a reddening flush began to spread across her face, shoulders, and arms, and on her legs. Her fever went up, and her backache grew worse. Her skin remained smooth, and no pustules appeared, although the reddening deepened in color. When the doctors pressed their fingers on her skin, it turned white under the pressure, but when they released their fingertips the blood came rushing back in a moment, filling under the skin. The doctors recognized this sign, and it was very bad.
I DON’T KNOW
how much the doctors told Birke of what they understood was coming. The red flush across her face deepened until she looked as if she had a bad sunburn, and then it began to spread downward toward her torso. It was a centrifugal rash that had begun on the extremities. She developed a few smooth, scattered, red spots the size of freckles across her face and arms. More red spots began to appear closer to her middle, following the movement of the creeping flush. She was forbidden to have any visitors, and there were no telephones at Wimbern that the patients could use. She couldn’t speak with her family.
The red spots began to enlarge, and there were more and more of them. They began to join together, like raindrops falling on a dry sidewalk, gradually darkening the pavement: she was starting to flood with hemorrhages beneath the skin.
Her back hurt, but the change in her skin was painless, and she prayed and tried to remain optimistic. Her skin was growing darker and soft and a little puffy. It was slightly wrinkled, like the skin of an old person.
The red spots merged and flooded together, until much of her skin turned deep red, and her face turned purplish black. The skin became rubbery and silky smooth to the touch, with a velvety, corrugated look, which is referred to as crêpe-rubber skin. The whites of her eyes developed red spots, and her face swelled up as it darkened, and blood began to drip from her nose. It was smallpox blood, thick and dark. The nursing nuns, who were wearing masks and latex gloves, dabbed gently at her nose with paper wipes and helped her pray.
Smallpox virus interacts with the victims’ immune systems in different ways, and so it triggers different forms of disease in the human body. There is a mild type of smallpox called a varioloid rash. There is classical ordinary smallpox, which comes in two basic forms: the discrete type and the confluent type. In discrete ordinary smallpox, the pustules stand out on the skin as separate blisters, and the patient has a better chance of survival. In confluent-type ordinary smallpox, which Los had, the blisters merge into sheets, and it is typically fatal. Finally, there is hemorrhagic smallpox, in which bleeding occurs in the skin. Hemorrhagic smallpox is virtually one hundred percent fatal. The most extreme type is flat hemorrhagic smallpox, in which the skin does not blister but remains smooth. It darkens until it can look charred, and it can slip off the body in sheets. Doctors in the old days used to call it black pox. Hemorrhagic smallpox seems to occur in about three to twenty-five percent of the fatal cases, depending on how hot or virulent the strain of smallpox is. For some reason black pox is more common in teenagers.
The rims of Barbara Birke’s eyelids became wet with blood, while the whites of her eyes turned ruby red and swelled out in rings around the corneas. Dr. William Osler, in a study of black-pox cases at the Montreal General Hospital that he saw in 1875, noted that “the corneas appear sunk in dark red pits, giving to the patient a frightful appearance.” The blood in the eyes of a smallpox patient deteriorates over time, and if the patient lives long enough the whites of the eyes will turn solid black.
With flat hemorrhagic smallpox, the immune system goes into shock and cannot produce pus, while the virus amplifies with incredible speed and appears to sweep through the major organs of the body. Barbara Birke went into a condition known as disseminated intravascular coagulation (DIC), in which the blood begins to clot inside small vessels that leak blood at the same time. As the girl went into DIC, the membranes inside her mouth disintegrated. The nurses likely tried to get her to rinse the blood out of her mouth with sips of water.
In hemorrhagic smallpox, there is usually heavy bleeding from the rectum and vagina. In his study, Osler reported that “haemorrhage from the urinary passages occurred in a large proportion of the cases, and was often profuse, the blood coagulating in the chamber pot.” Yet there was rarely blood in the vomit, and somewhat to his surprise Osler noticed that some victims of hemorrhagic smallpox kept their appetites, and they continued to eat up to the last day of life. He autopsied a number of victims of flat hemorrhagic smallpox and found that, in some cases, the linings of the stomach and the upper intestine were speckled with blood blisters the size of beans, but the blisters did not rupture.
At the biocontainment unit at Wimbern, the victim’s deterioration occurred behind the chain-link fence, in a room out of sight. Dr. Paul Wehrle may have visited her (he thinks not), but there was nothing he could have said to her that would have helped, and nothing any doctor could do for her. He had seen hundreds of people dying of hemorrhagic smallpox, and he no longer felt there was any medical distinction among types and subtypes of the bloody form, that it was all an attempt by doctors to impose a scheme of order on something that was just a mess. By the time I spoke with him, the cases had flowed together in his mind, and he felt there was an inexorable sameness in the patients as the bleeding and shock came on. “It was perfectly horrifying,” he said.
Barbara Birke remained alert and conscious nearly up to the end, which came four days after the first signs of rash appeared on her body. For some reason, variola leaves its victims in a state of wakefulness. They see and feel everything that’s happening. In the final twenty-four hours, people with hemorrhagic smallpox will develop a pattern of shallow, almost imperceptible breaths, followed by a deep intake and exhalation, then more shallow breaths. This is known as Cheyne-Stokes breathing, and it can indicate bleeding in the brain. She prayed, and the nuns stayed with her. The Benedictine priest, Father Kunibert, who had offered communion to Peter Los, ended up at Wimbern himself with a mild case of smallpox. He may have given Birke her last rites. As the end approaches, the smallpox victim can remain conscious, in a kind of frozen awareness—“a peculiar state of apprehension and mental alertness that were said to be unlike the manifestations of any other disease,” in the words of the Big Red Book. As the cytokine storm devolves into chaos, the breathing may end with a sigh. The exact cause of death in fatal smallpox is unknown to science.
PEOPLE WHO
are coming down with smallpox often exhibit a worried look, known as the “anxious face of smallpox.” A five-year-old girl named Rialitsa Liapsis, who came from a Greek family living in Meschede, got a worried look and broke with severe pustulation in the Wimbern isolation unit. She had been in a room at St. Walberga diagonally across the hall from Peter Los, suffering from meningitis, though she had never seen Los’s face. Rialitsa spent eight weeks recovering from smallpox in the Wimbern unit, sobbing every day for her parents, who were forbidden to see her. The little girl shared her room with Magdalena Geise, a nursing student who had worked on the second floor and had never seen Los but had broken with severe ordinary smallpox. On the day after Barbara Birke died, Magdalena Geise lost her memory completely and blanked out for three weeks. Finally, as her scabs fell off and her mind returned, she did her best to comfort the scared little girl who was crying in the bed on the other side of the room. She did all she could for Rialitsa Liapsis. Magdalena was in Wimbern for twelve weeks, longer than anyone else, and when she emerged she had gone bald, and her face, scalp, and body were a horrendous mass of smallpox scars. She returned to work as a student nurse in the hospital, and wore a wig, but the patients were frightened by her appearance, and the doctors finally had to take her off the ward. A year later, Magdalena Geise’s hair began to grow back, but it would take her ten years to get over her feelings of embarrassment about her appearance. Her religious faith helped her. Eventually, she married, had children and grandchildren, and found deep happiness and fulfillment. Her appearance today is that of a normal middle-aged woman with no disfigurement. Rialitsa Liapsis grew up and had children, and today the two women are friends.
Barbara Birke had had a friend at the hospital, another nursing student, Sabina Kunze, a tall, angular young woman with blond hair. Birke’s death left an opening in the cloister, and Kunze decided to take her friend’s place, and she made the vows and devoted her life to the work that she felt her friend would have accomplished had she lived. In the stories of Rialitsa, Magdalena, and Sabina, we see that the human spirit is tougher than variola.
Most of the people who broke with smallpox were patients and staff from the second and third floors of St. Walberga, and almost none of them had seen Peter Los’s face. Doctors Richter and Posch, along with Wehrle, traced the spread of the virus and concluded that seventeen of the victims caught the virus directly from Los. Two other victims caught it from people who had caught it from Los. One of the people who caught it from him was a nun in a room in the cloistered corridor on the third floor. She survived, but another nun who was put in her room afterward came down with smallpox, went confluent, and died.
A man named Fritz Funke had arrived at the hospital one day to visit his sick mother-in-law, who was in the isolation ward at the same time Los was there. Funke waited a few minutes in a lobby, then put his head up to a door that was propped open a crack. The door opened onto the isolation corridor. Funke pleaded through the crack with a doctor to let him in, but the doctor forbade it. During the minute or so that Fritz Funke had held his face up to the door, he inhaled a few particles of variola. He had been vaccinated as an adult, in 1946, but his immunity had worn off, and two weeks later Funke was rushed to Wimbern inside a plastic bag. He survived a wicked case of smallpox. Today, the bioemergency planners know Fritz Funke as the Visitor, and they wonder about his case and see it as a disturbing example of variola’s ability to spread easily through the air out of a hospital to a vaccinated visitor who barely poked his head into a ward. In the end, there were nineteen cases of variola after Los’s, and there were four deaths.
Peter Los entered the stage of crust, in which the pustules begin to lose their pressure. They can rupture and leak, and they begin to develop into brown scabs that cover the body. During this phase, the bed linens of the victim become drenched with pus and extremely offensive. This was the most dangerous phase of the illness, for death often happens at the beginning of the crust, just as the patient seems to be turning the corner. But Los pulled through, and eventually they set a date for his release. A German television show called
Tage
found out about it and made plans to interview him, but he had no interest in being seen by millions. Two days before he was due to be discharged, he either climbed the fence or someone let him out, and he went home to his family. Eventually, he left Meschede, moved to West Berlin, and took various odd jobs there. It is said he went to Spain and lived on a houseboat for a time.
ONE COLD, DRY DAY
in April 1970, three months after Peter Los had been admitted to the hospital, an expert in aerosols from West Berlin arrived at St. Walberga, bringing with him a machine for making smoke. Doctors Wehrle, Posch, and Richter wanted to find out exactly how the virus had traveled through the hospital. The smoke man placed his machine in the middle of Los’s old room and loaded it with a can of black soot. The doctors raised the window a couple of inches, in a re-creation of what Los had done when he disobeyed the nuns. They also left the door to the lobby propped open a crack, as it had been during the outbreak, when Fritz Funke had put his face up to it and come away infected with smallpox.
The smoke man switched on his machine, there was a whining sound, and a cloud of black smoke poured out of a nozzle and headed for Los’s door and billowed down the hallway of the isolation ward. Paul Wehrle ran along with it. The smoke went through the cracked-open door and poured into the lobby, and from there it boiled up the stairs to the second floor and then went to the third floor. As it came out of the stairwell it drifted along the upper hallways. It got through the closed doors of the cloistered hallway on the third floor, and it sprinkled a number of sick nuns with black dust.