Masunda

Lance Guma: Good evening Zimbabwe and thank you for joining me on another exciting edition of Question Time. My guest tonight is the Mayor of Harare, Mr Muchadeyi Masunda and the basis for this interview as has been pointed out in our promos is that despite the formation of a coalition government in 2009, Harare and several other cities still face serious water problems.

So we’ve got the Mayor onto the programme to try and tackle questions around this and many other issues. Let’s start off with the water problems, why do we still have them?

Muchadeyi Masunda: Good evening listeners.

The water situation boils down to simply the inadequate capacity in terms of the water treatment facilities, to treat the raw water and make it available to the consumers.

Now just to give you an example to bring things into sharp focus, the demand for water within Greater Harare and including Chitungwiza, Norton, Ruwa and Epworth, during the winter months it’s 1200 mega litres a day.

During summer months like now, it goes up to 1400 mega litres a day and the installed capacity at the main water treatment plant which is Morton Jaffrey, that is the plant that abstracts water from Lake Chivero and Lake Manyame, the installed capacity and I think you will need to understand this, the raw water is there in those two large reservoirs namely Lake Chivero and Lake Manyame.

What is not there is the capacity to treat that water because the capacities out there now at Morton Jaffrey is 614 mega litres a day.

Guma: so what’s needed to increase this capacity? What’s needed?

Masunda: Well what ought to have happened in the past, say around the mid-seventies was for the capacity that I’m talking about to have been enhanced for that water treatment facility to be able to treat more than it does at the moment.

And the second water treatment facility is a replica of Morton Jaffrey and that is the Prince Edward Water Treatment Plant which is more popularly known but its acronym, PE and that plant abstracts water from Harava and Seke dam and the installed capacity there is 90 mega litres.

So we have the combined installed capacity of 614 plus 90 which makes it a total of 704 mega litres. so on a good day, ZESA permitting, we produce between 620 and 640 mega litres which is a far cry from the 1200 that is required during the winter months and the 1400 which is required in summer.

Guma: When you came in as Mayor, you came in on the back of a promise to use your vast experience in business and your contacts in business to be able to source these things and take care of the problems. what has happened?

Masunda: Well I can proudly say that since I came into office the production of potable water has increased from around 300 to the 620, 640 that I’m talking about. so that’s a considerable improvement and what must be borne in mind, is that when we came into office in July 2008, the systems were kaput in more ways than one.

Not only were the systems kaput because of some serious neglect that borders perilously close to criminal negligence but there were huge sums of money which were owed and that situation got worse with the advent of dollarization because at the end of January 2009, we wrote off as a City, all the Zim dollar denominated balances and started from scratch like everyone else and as we speak, we are owed in excess of 200 million dollars by various consumers ranging from individual consumers, corporate consumers and government ministries and government agencies.

Guma: so are you saying if that money was to be paid, you would be able to develop the capacity and supply enough uninterrupted water?

Masunda: yes it would make a huge difference, a huge difference and I’m pleased to say that there’s been an appreciable reduction of the amount that had been owed by government.

For instance, as at the end of January the amount owed by government has come down to around 48 million and yet a couple of months ago it was creeping closer and closer to 100 million; But the amounts owed by the corporate sector and individual consumers are nearer 100 million in this instance and close to 200 million.

Guma: what are the figures here in terms of what you need to supply water uninterruptedly? What’s the figure because a lot of questions from listeners, we have one question from Mina Yetu on Face Book for example, who wants to know who is to blame for this water crisis – the central government or the local government?

Masunda: No I don’t think it’s in anyone’s interest to, for us to play the ‘blame game’ because that’s not going to put water on the table. what I think we need to do is to all of us to put our shoulders onto the wheel and honour our obligations and pay the bills as and when they fall due in spite of the fact that in certain instances, many of us would not be receiving the service.

And for instance, there’s work that we are doing to reclaim water for instance from the (inaudible) plant that had been installed a couple of years ago but had been abandoned because there weren’t enough funds and what that we’re doing there is going yield a considerable amount of water, this is reclamation system whilst we work on the longer term projects.

And the other thing that needs to be done and done very quickly like yesterday is for us to replace the piping system which had rotted over the years. You will recall no doubt that around I think 2009 we managed to get 17.1 million dollars, courtesy of the multi-donor trust fund and we used all that money to replace the piping system within the CBD and certain industrial areas. so we need to do more of that so that there’s less water lost, treated water lost and make that water available.

Guma: The issue of people receiving bills when they haven’t received a service – that’s a sore point for a lot of residents and we’ve received several emails on that; people are not happy with that. why should they pay for something they are not receiving?

Masunda: And what is the alternative? only two weeks ago I paid a total of one thousand nine hundred dollars to ZESA; I’d not received a ZESA bill for quite a while and I’d been dutifully paying round about a hundred dollars, two hundred dollars every month waiting for the statement to come and when that statement eventually came it was one thousand, eight hundred and sixty five dollars and I paid it in good faith because it’s a chicken and egg situation.

You know we are in a deep, deep hole as a country and a city and I think what we need to do is to stop looking backwards as to what got us into that deep hole and all look for solutions on the way forward.

Guma: But people will say it’s just impunity on your side as people in authority, you’ll just demand whatever you want, even including making people pay for services they are not receiving. why not provide the service and then expect money in return for it?

Masunda: There’s no, I’ve no qualms at all with that argument but people need to realize that all the services that are, need to be offered have a cost in terms of real money and that money’s got to come from somewhere and a lot of people are labouring under the mistaken belief that the City of Harare and other urban local authorities get something from cabinet. We don‘t.

We have to generate our own revenue and that has been the case even long before independence and that money has got to come from somewhere. Money doesn’t grow on trees, we all know that.

Guma: I’ve been sifting through the 2012 national budget and in terms of resource allocation it seems pretty clear that and it’s feeding a lot of resentment from a lot of people that some things like foreign trips are being prioritized by government, luxury cars being prioritized by government and when people hear you say there’s no money to do a, B, C, D it makes them angry.

Masunda: yes, understandably angry but it’s not for me to speak on behalf of these expensive chariots that are procured for government but what I can do is to speak on behalf of what happens in the City. to give you an idea – if we were to commission this large disposal and water reclamation plant at Morton Jaffrey Waterworks and that’s at a cost of seven million dollars that will immediately avail an additional 40 mega litres of potable water a day.

And if we were to rehabilitate the, some of the clarifiers at Morton Jaffrey and the total cost we estimated will be around eight million, that will increase the water production by another 57 mega litres a day. And then of course, we’ve got to start working on the distribution network and we’re looking at another 60 million dollars and that will make another 100 mega litres of water available because a lot of water, as much as 50, around, over 40%, closer to 50% is being lost through leakages and theft, vandalism and pilferage.

Guma: My next question comes from Mike Davis, I’m sure you know him – a former chairperson of the Combined Harare Residents Association – he says “when he (Masunda) was mayor, we lost 4000 plus citizens to cholera, yet two years later we are facing typhoid. what has he done to address these symptoms of failure?”

Masunda: Well the 4000 poor souls who lost their lives, it wasn’t all in Harare, it was throughout the country and as far as typhoid is concerned, I’ll be the first to admit that the principal drivers of the typhoid outbreak were inadequate supply of potable water, sewerage overflows due to overload, high water table caused by the ongoing wet season and of course the erratic refuse collection which has resulted in a number of illegal dumps.

But touch wood, out of all the suspected cases of typhoid that have gone through our clinics and the two hospitals, we talk as at the 16th of February, we had about 2816 and out of those suspected cases of 2816, there were only 16, one six of confirmed cases and the suspected typhoid deaths are only two; one 15 year old girl who had been treated at the Beatrice Road Infectious Diseases Hospital and was discharged and if the parents had religiously followed the treatment regime that had been given and not decided to, that they belong to some religious sect that did not permit medication that poor 15 year old kid should still be alive.

And the only other death was an eight month old baby and then there was another lady, an elderly lady who came in on the verge of death and subsequently died but we established that her death was attributable to other causes that were not remotely connected to typhoid.

Guma: It seems to me pretty much some of these problems are also stemming from the water problems the city is facing. Hearing you giving answers to what the problem is – what’s the long term solution because it seems to be a chicken and egg dilemma?

What starts first – money from the residents paying for a service they’re not getting? do you need a bail out from government? Does government need to change its priorities and get something going because year after year the same problem remains and nothing is changing?

Masunda: Well we’ve never seen a typhoid outbreak on the scale that we’ve seen now but I’m pleased to say that we’ve contained the situation. The average number of suspected typhoid cases has come down from about 72 to 30 a day and we need to keep a beady eye on all these things.

But we also need to get the cooperation of the stakeholders themselves. People must refrain from patronizing all these joints like Kwa Mereki, Kwa Zindoga, Pennywise Liquor Centre, Ku Huku in Hillside, Braeside because those are the epi-centres of water-borne diseases.

And due to chronic unemployment we’ve seen a proliferation of food vending in the city and surrounding areas and I’m very concerned about what may happen now that the Tobacco Auction Floors have opened because some of our new tobacco growers will come in from outside Harare and they’re going to camp either at Boka Tobacco Auction Floors or the other two new ones that have been established, until they get paid.

Guma: But is the solution closing places like Kwa Mereki and others or providing proper facilities for such informal kind of businesses to thrive?

Masunda: That’s a good point. It’s a combination of both. For instance, one of my very, very strong beliefs when I came into office was to work very closely with those enterprising ladies at Kwa Mereki and convert that into some serious cottage industry.

But when I went there and spoke to Mai George and others and I said ladies how do you dispose of the litter that is generated here, they took me to the back of where they were operating – a pit where they were mixing up all sorts of garbage, biodegradable stuff and bottles and cans and plastics.

And courtesy of Delta Beverages we provided them with compartmentalized wire mesh cages, so that they put the bio degradable stuff in the pit and the cans on their own, the plastic bottles and their own and the glass on their own so that the reclamation companies can cart that away.

And I’m pleased with the efforts that have been made following the closure of Mereki in the last week and first week of, last week of January and first week of February, they’ve taken it upon themselves to address some of the issues that ought to have been addressed a long time ago.

Guma: And just quickly on that, several questions on that, maybe final question just for this week – when is Kwa Mereki opening?

Masunda: as soon as I get the nod from the City Health Department that all their concerns from the health perspective have been addressed.

Guma: Well Zimbabwe that’s the Mayor of Harare, Mr Muchadeyi Masunda, because of time constraints we’ll probably have to split it again in two and have him again next week so that I can finish all the questions that you the listeners sent in. Many thanks to Mayor Masunda for joining us on part One.

Masunda: thank you and I look forward to taking part in the next segment.

To listen to the programme:

swradioafrica.2bctnd.net/02_12/qt220212.mp3

Feedback can be sent to lance@swradioafrica.com twitter.com/lanceguma or facebook.com/lance.guma

After starting off this year with a horrid bang, a double fatality on New Year’s Day followed by a political crisis that is still far from resolved, we will, like it or hate it, thank our lucky stars that Eurovision exists. this will, for a few brief evenings, take our minds off Arab springs and deadly cold snaps!

… the Emergency Department must look like a scene out of Dante’s Inferno at this period of the year- Kenneth Zammit Tabona

Yes; life goes on, with or without Lawrence Gonzi or Joseph Muscat playing politics because a rebellious and obviously rebellious backbencher got off his sit-upon to deliver some home truths in such a way as to rock both the Nationalist and the Labour boats.

So, as we concentrate on Kurt Calleja’s delivery and interpretation of this is the Night, we can put the politicos on the back burner… or can we?

I am quite convinced that, should Malta lose yet again, the PL supporters will blame Tonio Borg’s foreign policy while the PN will somehow invent some convoluted reason to blame Dr Muscat. Alternattiva supporters will probably say that they could have performed better themselves but that nobody gave them the chance to!

I am very much a believer in solutions and not problems per se. one of my greatest mentors was the late Judge Riccardo Farrugia who was chairman of Mid Med Bank between 1989 and 1992 and in whose secretariat I worked. Dr Farrugia’s affability and charm was coupled with a razor-sharp and analytical brain that was invariably able to strike at the root of any problem and, because of his positive disposition, immediately propose not one, not two but several solutions.

If only life could always be like that. I am recounting this appreciation of this exceptional man because I thought of him so much while reading the long list of grievances put forward by 60 nurses about Mater Dei Hospital. It does not contain one little hint of a proposal to solve these very serious lacunae in the set-up that is detrimental both to the nurses themselves and, even more, the thousands of patients who are served each and every day for free or, rather, at the expense of those who pay taxes.

The fly in the ointment is always the Emergency section wherein, as I have observed several times previously, there seem to be more security personnel than medical. no wonder, when the infrastructure seems far from ideal with as many as 30 per cent of patients ending up there who should never have been there at all. Not to mention that nobody has either the time or inclination to give anyone, least of all agitated sick people and their even more agitated loved ones, any logical and acceptable reason for the never-ending wait.

I have said it before and I will say it again, all that entire place needs is good management and some empathic interaction between the nursing staff and the patients. they must understand that no matter what pressure they are under, a smile costs nothing and a two-minute explanation can go a long way to allay mounting tensions, which is what being at Emergency is all about.

The Riccardo Farrugia solution is so beautifully logical and simple and, yet, nobody has had the gumption to implement it and, therefore, the system limps on. It gets worse and worse in times like these when pernicious germs are aided and abetted by cold snaps that take their toll on the very old and the very young.

Of course, the Emergency Department must look like a scene out of Dante’s Inferno at this period of the year. However, I have confidence in our medical and nursing staff as we need not read about the unsung heroism of the medical and nursing staff during the cholera epidemic in Naples, as unforgettably described by a great author like Axel Munthe in his story of San Michele, but simply recall what we have just seen broadcast on the international newsrooms. we saw interviews with doctors and nurses working round the clock in war-torn countries like Libya in which our own compatriots were heavily involved. they are unsung heros.

This is why the system needs to be re-examined. For all it’s worth I will share a small personal experience, which may indicate what is radically wrong with the system.

About a year ago, I developed an allergic reaction after having eaten a piece of toast with processed tuna paste spread. I was alone at home and suddenly my head started to pound horribly, my body was gripped by a dry heat and when I looked in the mirror my skin had gone the colour of Roman terracotta.

I immediately looked up the symptoms on the internet and, lo and behold, it homed in on the tuna straightaway and said that what I needed was an antihistamine injection ASAP. So I jumped into my car and dashed off to the polyclinic in G?ira to be told that they had no antihistamine injections. I was told that to have this injection I was to go to Floriana. “Righty-ho,” said I, still looking like Sitting Bull with petards going off in my head, “I’ll go to Floriana.”

Till that moment they did not realise that I had driven myself but now they panicked and expressly forbade me to drive at all as they said I could choke… So not having an ambulance at their disposal I had to try various relatives on a late Sunday night till one of them came to take me to Floriana by which time, thankfully, the allergic reaction was on the wane.

I could have saved myself all this hassle by having driven myself to Mater Dei’s Emergency where, presumably, they must have stashes of antihistamines but because I did not think what I had was serious enough I didn’t and, consequently, drew the short straw.

One can never get it right, can one?

It was a typical day in late may 1982. the last blooms still hung onto the azaleas. In Charleston, tourists, like fireflies at night, has descended on the Holy City for the start of the sixth annual Spoleto Festival of the Arts. but Dr. Robert Ball Jr. had more on his mind than symphony orchestras and classical music performances. As he prepared to see patients at his infectious disease clinic in Charleston’s West Ashley neighborhood, his phone rang. a family practice physician called seeking an infectious disease consultation for a desperately ill patient.

As an infectious disease specialist, Dr. Ball had grown accustomed to such pleas for help, doctors referring strange cases of tropical diseases to him for care. In less than a decade of medical practice he had developed the reputation of being something of a storm chaser of the infectious diseases that surfaced in the Low Country of South Carolina, an area characterized by viciously hot and humid summers, extensive marshes, and, of course, mosquitoes.

The physician on the other end of the phone line had admitted his patient to St. Francis Xavier Hospital for observation. He was at a loss to determine what ailed the young white man. without hesitation, Dr. Ball promised to see the patient that day. it was a short drive from his office to the hospital, which had been founded by the Sisters of Charity of Our Lady of Mercy in 1882. When Dr. Ball walked into the private hospital room, he saw a patient who looked to be in his late teens or early twenties. He quickly learned that for several weeks the patient had been suffering from high fevers and swollen lymph nodes. a chicken pox-like rash covered his entire body. Lesions pockmarked his frame, with open, raw sores draining clear fluid. Herpes-like lesions covered his genitals and perineum, the area between his scrotum and anus. on close examination, Ball also noticed that the man had thrush, a yeast infection of the mouth that doctors would later associate closely with being HIV positive.

The young man’s swollen lymph nodes signaled trouble. His herpes clearly had been contracted sexually; another disease might have been lurking inside him for several years before trashing his immune system. the symptoms had become too obvious to ignore. whatever the reason, his health was deteriorating rapidly. “It was the worst case of genital herpes I had ever seen,” Dr. Ball says. “Normally, genital herpes doesn’t spread throughout your body. In his case, it did.”

Thankfully, Dr. Ball determined, the patient didn’t have the pneumocystis carinii pneumonia (PCP) or the cancers that physicians had quickly discovered were common among people with AIDS. Of more immediate concern was his extremely low white blood cell count. “There were a number of other lab abnormalities that indicated a systemic infection that was probably viral,” Dr. Ball recalls, speaking with an even, genteel southern inflection that could have come straight out of a Pat Conroy novel.

In addition to his private practice, Dr. Ball also taught at the Medical University of South Carolina (MUSC), his alma mater, and knew the lab staff of the huge facility. After he examined the patient, he immediately ordered additional blood tests and further analysis of the man’s white blood cells. When the patient’s MUSC lab tests came back a week later, they showed an extremely low number of what are now called CD4 lymphocytes. Back then they were called OKT3 lymphocytes. Having low CD4 cell numbers increases the risk of opportunistic infections, leaving an individual as vulnerable as a battleship floating on the high seas without guns. Simple pneumonia could be as lethal as the bubonic plague. Troubled by the initial test results, Dr. Ball ordered more tests. As he awaited the results, he ran through all the possibilities. Little did he know that fateful doctor-patient encounter in St. Francis Hospital on that spring day would turn his comfortable, white, middle-class world upside down, change the course of his professional and personal life, and shake long-held political and spiritual beliefs, transforming him from a white southern Barry Goldwater conservative to that rarest of species, a white southern progressive.

Robert Ball’s links to Charleston and the Low Country are as deep and as storied as the region itself. His ancestors first settled on the land when South Carolina was still a colony, more than 320 years ago. the pages of the telephone book are peppered with Balls. He served as president of the Society of first Families of South Carolina, a genealogical organization that documents and celebrates the history of the earliest colonial settlers.

Young Robert grew up in the West Ashley section of Charleston. He played football in high school but was never great at it. His passion was books. He spent hours locked away in his bedroom devouring science books. After high school, unlike many South Carolina blue bloods, he didn’t head west for the University of South Carolina in Columbia or even Clemson upstate. Robert remained closer to home. He drove less than half an hour to the College of Charleston, where he studied biology and chemistry. to no one’s surprise, he wanted to be a doctor.

Little did he know that fateful doctor-patient encounter in St. Francis Hospital on that spring day would turn his comfortable, white, middle-class world upside down.

In college, Robert, an avid boater, helped form the school’s first sailing team. He dabbled in Republican politics and a lot of campus life. His old college yearbooks showed that Robert also was involved with at least four campus organizations each year. He led a Charleston chapter of the John Birch Society, a group that was founded in 1958 by former candy industry executive Robert Welsh, who spouted an ultraconservative brand of pseudo-Christian anticommunism, nationalism, and antiglobalism. John Birch Society members called for the repeal of the federal income tax on constitutional grounds, sought the abolition of the Federal Reserve and the United Nations, and viewed the civil rights movement as the vanguard of a communist plot. In 1964, like most other John Birch Society members, Ball supported Barry Goldwater. the conservative Arizona senator had lost to Nixon in the 1960 Republican primaries but prevailed against moderates Governor Nelson a. Rockefeller of New York and Governor William Scranton of Pennsylvania before being trounced by the incumbent president, Lyndon Johnson, in 1964.

Two years later, after he graduated from the College of Charleston, Ball followed a path he seemed genetically bred to pursue. He drove across town and enrolled at what was then the Medical College of South Carolina, an institution whose desks, chairs, and labs were stained with the sweat of his forebears. Ball is descended from a line of physicians seven generations deep. His great-grandfather was a doctor; a number of great-uncles were too. One uncle was a physician; another, Benjamin M. Martin, was chief radiology technician at MUSC for over two decades. both grandfathers were doctors, and his paternal grandfather, Dr. James Austin Ball, was the medical school’s first professor of infectious diseases, then called tropical medicine, at the turn of the century. His maternal grandfather, Dr. Thomas Hutson Martin, graduated from the College of Medicine in 1919 at age 19 before launching a long and distinguished career as a physician and surgeon in Charleston. Dr. Martin was a longtime member of the Charleston County Board of Health and an assistant professor of surgery at the medical school. He retired from practicing medicine in 1951. Later, Ball would donate Dr. Martin’s class ring to the medical school’s Waring Historical Library.

The oldest medical school in the Deep South, the Medical College of South Carolina was founded in 1824 and kept its name largely intact for 145 years. but by the time Ball donned his cap and gown to accept his medical degree in 1970, the college had been renamed the Medical University of South Carolina. He helped put himself through medical school by working days as an anatomy instructor and nights in the MUSC microbiology lab. for his medical internship, he drove 470 miles west on Interstate 20 to the University of Alabama-Birmingham, which was located in a city that had come to symbolize southern white resistance to the struggle for black civil rights. but less known at the time was that its hospital was a vital training ground for infectious disease specialists. Later it would be home to several pioneers in the fight against HIV and AIDS.

Ball began his medical internship, now called a residency, in Birmingham the same year George Wallace returned in triumph to the governor’s mansion for a second four-year term. Wallace was still a rabid segregationist who opposed equal rights for people of color. the young Ball admired Wallace’s uncompromising segregationist anti-civil rights platform. that was before his epiphany; that was before AIDS, before he saw firsthand the machinery of white privilege and southern prejudice, once reserved exclusively for people of color, unleashed on white gay men with a deadly, demoralizing new sickness.

Wallace and his politics of derision appealed to Ball at his deepest core. on holidays he drove east to Charleston, proudly showing off the Wallace bumper stickers on his car. those stickers multiplied as Wallace ran again for the presidency in 1972 after his failed bid in 1968.

Parents, classmates, and friends weren’t surprised by Ball’s affinity for Goldwater and Wallace. like most well-off southern white men, Ball grew up in a very politically conservative family, even though their hometown, Charleston, was becoming increasingly liberal. His family was Republican, the kind who scoffed at northeastern Republican moderates. Ball, still a fervent anticommunist, spent years licking his wounds after Senator Goldwater’s 1964 defeat at the hands of LBJ.

That decisive election was to have a direct impact on Ball’s fate. After his re-election, Johnson escalated America’s involvement in Vietnam. for the next six years, rural southern boys and inner city kids in their teens and early twenties were drafted and shipped, weapons in hand, to the jungles of Southeast Asia. Ball’s medical internship only delayed the inevitable. the draft board gave him permission to finish his training. Sooner or later the army would beckon. As the war in Vietnam dragged on, even white boys of privilege couldn’t avoid doing their share in the increasingly unpopular war. the summer Americans first heard about the Pentagon Papers, when protestors in Washington tried to bring the federal government to its knees, Ball, now at the end of his internship in Birmingham, received the long-feared letter — a direct order to report to the draft board in Charleston. Days later, he walked into the draft board office in Charleston and swore his allegiance to defend the country. He was lucky. the army wanted to send him as an orthopedic surgeon to the combat zone in Vietnam, where American GIs needed able surgeons to repair the damage wrought by Vietcong booby traps. but his skills did not lie in the operating room. “You want me with a pen in my hand, not a scalpel,” he joked years later. “No wonder we were losing over there.”

Ball spent his two-year tour of duty working as medical director of the emergency department at the massive William Beaumont Army Medical Center complex in El Paso, Texas, which serves neighboring Fort Bliss. By the time he was honorably discharged in 1973, the end was in sight for the U.S. military involvement in Vietnam, but the country had just begun a spiral toward another prolonged political crisis — Watergate.

Ball returned home as expected to Charleston, where for the next two years he pursued an internal medicine residency, followed by a 24-month infectious diseases and immunology fellowship at his alma mater, MUSC. Ball was hardwired not just to study medicine but also to hunt infectious diseases, just like his paternal grandfather, Dr. Ball, who in the early 1900s taught dermatology and tropical diseases. Graveyards in the South are filled with children and young people victimized by smallpox, yellow fever, and cholera. Sexually transmitted diseases, especially syphilis and gonorrhea, ran rampant through the poor sectors, especially the black population. while he was serving in the army, Ball contracted viral meningitis, a relatively common but rarely serious infection of the fluid in the spinal cord and surrounding the brain. Viral meningitis and other infectious diseases fascinated Ball. After he was discharged from the military, he hoped to pursue a specialty that offered the daily challenge of trying to cure people with the new and exciting antibiotics being introduced daily rather than deal with terminal conditions like cancer. but the good Lord had other ideas.

His long journey to becoming a physician complete, Ball opened a private practice in the West Ashley section of Charleston in 1977. Jimmy Carter had been elected to the White House a year earlier. America was still struggling to rediscover its self-confidence. while he built his fledgling practice, Ball taught part time at MUSC, honoring his family legacy.

While Dr. Ball taught infectious diseases, elsewhere in the massive MUSC complex a high-cheekboned black woman, Annie Mae Pegram, cheerfully endured the pricks and prods from physicians testing new cancer drugs. It’s unlikely that their paths ever crossed, but fate conspired to ensure that AIDS, the disease that dominated Dr. Ball’s private and public medical career, would also shape the life and cause the early death of Annie Mae’s youngest daughter, Carolyn.

Excerpted from Andrew J. Skerritt’s Ashamed to Die: Silence, Denial, and the AIDS Epidemic in the South (Lawrence Hill Books)

Though the death of a Syrian body builder Mahmoud Ibrahim Alhdidi, 29, has raised speculation that dehydration was the ultimate cause of death, experts say it is not always fatal.

Alhdidi, a participant of Mister Universe 2011 held in Mumbai, was declared dead a day before the competition began. He was supposed to be participating in the 75 kg category and was on a weight control regimen ahead of the event.

Preliminary reports blame dehydration for his death.

However, experts say that other effects which take place along with the dehydration could have caused the death. Dr. S. Jairam of Bombay Hosptial said, “Dehydration is a treatable condition in most cases and is not always fatal. Fatal cases may be caused only by excessive exertion, less fluids in the body or gastroentritis and sudden change in the blood pressure”.

Dr. Anuja Balose of Lilavati Hospital echoed Jairam. “In dehydration cases, the metabolism of the body stops completely which could lead to multiple organ failure if not treated in time,” she said.

She insisted that such cases are however, rare. “It is more common in extremely hot places or when there is an epidemic of diseases like cholera, mostly found in children and the elderly. It is very difficult to say that it can cause sudden death”.

Dehydration symptoms, such as diarrhea, vomiting, fever, shortness of breath, vapid pulse rate etc are noticeable when there is a loss of 2 per cent of the body’s normal water content.

It is known to be fatal in cases where the patient’s symptoms have been left untreated for longer than five days by loss of over 15 per cent of water.

“Alhdidi fell unconscious due to dehydration and was rushed to a hospital in Malad by the organisers where he was declared dead for suspected heart attack,” Indian Bodybuilding and Fitness Federation Secretary, Sanjay More said.

Western and central Africa are facing one of the biggest cholera epidemics in their history, the World Health Organisation and the United Nations Children’s Fund said last month, in reporting that more than 85,000 cases of cholera have been registered since the beginning of the year, with nearly 2,500 deaths.

Unicef has identified three main cholera epidemic outbreaks in the Lake Chad basin, the West Congo basin and Lake Tanganyika. The disease, which is spreading along watercourses, has been made worse by the recent rainy season. Five countries – Cameroon, Ghana, Nigeria, the Democratic Republic of the Congo (RDC) and Chad – account for 90% of the reported cases and fatalities.

Cholera is an acute intestinal infection caused by the Vibrio cholerae bacillus. It is still one of the clearest indicators of social development. The disease spreads through water, which has been in contact with the faecal matter of infected people, reappearing periodically in countries unable to secure access to clean drinking water and adequate sanitation.

Almost all developing countries are plagued by occasional cholera epidemics, facilitated by the short incubation period, which ranges from two hours to five days. but it is a long time since central and western Africa suffered such a serious epidemic.

“The highest rates of contamination are in Chad, Cameroon – where nine out of 10 districts are affected – and western RDC, where the mortality rate is over 5%,” Unicef spokeswoman Marixie Mercado said, adding that the rate is over 22% in some regions. these figures are particularly dramatic, given that with appropriate treatment – antibiotics and intravenous rehydration – mortality can be brought down to 1%.

One reason for the high mortality rate is the lack of medical care. a lack of public awareness is also a factor. The current peaks in the epidemic are in areas where the disease is not endemic, according to the UN agencies.

“We have just received reports of a sudden outbreak of cholera in the Central African Republic, where the disease has not been seen for years. That means people are less aware of how to prevent an epidemic and how to react,” Mercado said. in Congo the disease reappeared in September in provinces where it had not been reported in the past decade.

Most of the people infected display no symptoms and the bacillus may survive in their faeces for one to two weeks. If the disease does break out, 80-90% of cases are harmless or only moderately severe, making it difficult for doctors to distinguish them from other forms of acute diarrhoea.

So it is vital to raise individual and community awareness to prevent the disease from spreading, all the more so in countries where most people do not have access to clean drinking water and latrines.

The situation seems particularly serious in Chad, where the WHO had registered 16,000 cases and 433 deaths by 5 October. “Some 6,500 cases of cholera were reported in 2010 and the epidemic has never really stopped since. Whereas the period before the rainy season is usually fairly quiet, the first cases this year appeared in April, without us being able to identify the origin of the outbreak,” says Michel-Olivier Lacharité, the regional head of Médecins Sans Frontières. The epidemic has affected more than half of Chad’s health districts and in September it reached the area bordering on Sudan. since the beginning of the year, 350 MSF staff have been working there, spread over 23 sites.

“The worst of the epidemic is in the capital. outside N’Djamena we hope that the peak of the epidemic may be past, particularly with the end of the rainy season,” said Antoine Peigney, head of international operations at the French branch of the Red Cross, which has set up a cholera treatment centre. It aims to take charge of 65,000 people, comprising 3,000 patients receiving treatment, and thousands of families who will be targeted by campaigns to raise awareness of the importance of hygiene, which is essential to containing the epidemic.

This story originally appeared in Le Monde.

The United Nations World Health Organization (WHO) has provided essential drugs to help treat an outbreak of dengue fever that has affected an estimated 1,000 people in the north-eastern Kenyan district of Mandera, which borders Ethiopia and Somalia.

There have been four unconfirmed deaths and some patients have been showing symptoms of Dengue Haemorrhagic Fever, a more severe form of the disease, the UN Office for the Coordination of Humanitarian Affairs (OCHA), reported in an update.

All neighboring districts have been alerted and people advised to seek early medical attention if they become ill.

Meanwhile, anaemia prevalence among children under the age of five in the refugee camps in Kenya’s Dadaab area is above 40 percent, according to OCHA. the camps host nearly 470,000 refugees, the majority of them from Somalia.

Three of 6 suspected cases of cholera in the Dadaab camps have been confirmed and all the patients arrived recently from Somalia. Some 82 percent of the refugee population have received measles vaccination during a recent mass inoculation campaign.

An estimated 3.75 million people in Kenya have been experiencing food shortages a result of a prolonged drought in the Horn of Africa, and relief agencies are working with the Government to scale up distributions to the affected populations through one coordinated pipeline from October.

In August, the overall number of admissions to hospital of children with severe acute malnutrition declined from 6,379 to 5,560 cases, but an increase in admissions has been reported in the districts of Marsabit, Samburu, West Pokot and Laikipia.

BM/UN

Section: East Africa, Health

Through its media service, Jahon, the Uzbek foreign ministry appears to be denying claims that Uzbekistan is experiencing an outbreak of cholera. the ministry of health in Uzbekistan and the state epidemiological surveillance unit are also refuting reports of a cholera outbreak and are doing nothing to prevent the spread of the disease. “If we announce a cholera diagnosis, then we immediately have to organise quarantine, and nobody wants that,” said one doctor in the Tinchlik village hospital in Yangiyul district, Tashkent. Quarantine, he says, means that villages and towns where cholera has been identified have to be ‘shut down’, and clean drinking water has to be supplied, which is an extremely costly operation for the district authorities, especially in villages like Tinchlik. Hardly surprising to find cholera “We haven’t had clean water for 20 years. the old water pipes have crumbled but nobody has ever replaced them,” said Akramkhodzh Mukhiddinov, member of the Human Rights Alliance of Uzbekistan (PAU) and also a resident of Tinchlik. Mukhiddinov claims that many people who have their own transport bring drinking water from Yangiyul or Tashkent, but most people take water from waterways running through the area. “People take water from the irrigation channels, then boil it and drink it. there is no alternative when there is no clean mains water,” says Mukhiddinov. He claims that people most at risk of contracting cholera are those who take water from the Boz-Su river. “A 45-year-old man, who drank water from this river, died recently in our village,” Mukhiddinov says. the human rights campaigner believes that, given the living conditions in Tinchlik and its neighbouring settlements, it would be amazing if an outbreak of cholera did not happen here. Health ministry denies the outbreak Meanwhile, Uzbekistan’s health ministry and foreign affairs ministry are categorically denying reports of a cholera outbreak. “When you present them with concrete facts about people dying from an illness, the symptoms of which are extremely similar to those of cholera, ministry of health civil servants don’t respond, claiming that they have heard of no such instances.” one Tashkent journalist remarked. Uzbekistan’s state epidemiological service also denies the outbreak of cholera. “We are currently running a campaign to vaccinate children against measles and German measles, but have heard nothing about cholera. if there were cases, we would have made statements about this,” said one employee of the state epidemiological surveillance service in Chilanzar district, Tashkent. “The symptoms of cholera – vomiting and diarrhoea – are similar to those of other intestinal illnesses, and it is possible that people are mistaken about what is actually wrong,” an employee of the epidemiological surveillance unit speculated. When asked about cholera, the source asked us not to use his name. So where do we stand? Despite official denials, many doctors are saying confidentially that there are cases of cholera now in Uzbekistan. They do not hide the fact that people have died from an intestinal illness, the name of which doctors will not spell out to their relatives. “I am convinced my husband died of cholera after he swam in the Boz-Su river,” says Mukhabbat, a 30-year-old Tashkent resident. the outbreak of cholera would appear to be confirmed, at least, by events in Yangiyul district and in Yangiyul hospital, where, in mid-August, dozens of people arrived each day with symptoms of this disease – not only vomiting and diarrhoea but also severe dehydration. Previously, the Almazarsk district of Tashkent had experienced cholera-like illness, also linked to water from the Boz-Su river. “It is very easy to explain why information about a cholera outbreak is being hushed up, and you can see this in the text of the foreign ministry’s statement,” said one Tashkent doctor, who also asked to not to be named. “As a member of the World Health Organisation, Uzbekistan has to update the European regional office of this body round-the-clock, but if it did inform WHO about these circumstances, WHO would send out a special commission which would see for itself the terrible living conditions of those people who have contracted cholera,” he said. “Will our government allow that to happen?” an Uznews.net source asks, adding that as winter approaches, the cholera bacteria will become less active, and the cover-up may therefore outlast the outbreak. Uznews.net

Two boys play in a pool of water near Jet Lines in Karachi where 20 mm of rain fell on Monday. PHOTO: EXPRESS

KARACHI: Contrary to a deeply entrenched belief, playing in the rain does not make your child sick, doctors say.

“The real issue is to convince people how diseases break out,” explains paediatrician Dr Sohail Thobani. “They happen because of an attack on the body by germs which are usually transmitted from one person to another.”

This does not mean that precautions should not be taken. the chair of paediatrics and child health at Aga Khan University Hospital (AKUH), Dr Anita Zaidi, says timing matters. “While there is no harm in children playing in the rain, they should not stay drenched for too long,” she says. “Especially children under two years of age should not play in the rain for longer than an hour, it puts them at risk for hypothermia.” Young children can lose too much body heat if they stay in the water too long.

Parents should instead be concerned if their child is playing in standing water. “There is a good chance of them contracting a number of diseases from playing in standing water,” says Zaidi. This water is not purely rain water but is mixed with sewage that has a high fecal content. Standing water also becomes a breeding ground for mosquitoes, responsible for the spread of dengue. Children will also be at risk of diarrhoea and skin infections.

But as far as simply enjoying the monsoon rain and splashing around rain water is concerned, doctors say parents need not worry. “We have certain cultural perceptions and then we have scientific fact. the two are poles apart,” Dr Thobani says. “In medicine it will always be your grandmother who knows more than the doctor.”

When it comes to contact with water, parents need to understand the difference between two types of diseases: viral and bacterial. Viral diseases, such as the common cold, will treat themselves regardless of whether medication is used or not. Medication may help ease some of the symptoms but the illness is self-treating.

It is not that simple for bacterial diseases, whose treatment with antibiotics is debated by doctors. Typhoid, for example, which is transmitted from a germ spread through stool, needs to be treated with antibiotics. “That is why using an Indian toilet is more hygienic in some aspects as your body does not come in contact with the toilet seat,” Dr Thobani says.

On the other hand, Dr Zaidi says, “Antibiotics are not necessarily required for bacterial infections; however, it must be taken with diseases such as cholera and blood diarrhoea.” Pneumonia can have both bacterial and viral properties. but again this will not happen by just playing in the rain – you would have to come in contact with someone who is already infected.

Published in the Express Tribune, September 13th,  2011.

Note: Author’s footnotes have been omitted.

Chapter 1: The Diagnosis

Anthrax is a disease of animals, particularly sheep and cattle, and to a lesser extent man, caused by infection with Bacillus anthracis. — C. a. MIMMS, The Pathogenesis of Infectious Disease, 1987

Wednesday, September 26, 2001. Bob Stevens, a fifty-six-year-old senior photo editor for the national supermarket tabloid The Sun, was in his third-floor cubicle, hunched over his computer. The modern glass and concrete building where he worked, set in a landscaped office park in Boca Raton, Florida, was owned by The Sun’s parent company, American Media, inc. (AMI), whose headquarters were in Manhattan and whose business was big-circulation, celebrity journalism. The Sun and the National Enquirer were its weekly flagship moneymakers.

Stevens was rushing to meet his deadlines before taking a long weekend off. He and his wife, Maureen, were driving to North Carolina to visit their daughter Casey, a student at the state university at Charlotte. Bob was a Brit, gregarious and cheerful. Maureen, equally good-humored but more shy, had been born in Ireland. they had arrived in America in the early 1970s, when they were still in their twenties, and started a new life together. they became American citizens and settled in Florida, happily so. Both had been married before and were already parents, with three children between them, and then they had Casey, the last to leave the nest.

Bob had planned a packed agenda. He wanted to set out for Charlotte at the crack of dawn, go hiking with Casey on the Appalachian slopes near Chimney Rock, take a side trip to Durham to meet her boyfriend who was in school there, and then on Monday he and Maureen would drive back to their home in Lantana, about ten miles south of Palm Beach.

While Stevens edited photos on his computer, another AMI employee, Ernesto Blanco, was working in the first-floor mail room. a Cuban émigré, the wiry Blanco was seventy-two but had a thick head of hair and the stamina of a much younger man. Every morning he drove the company van to the local post office to pick up 10,000 to 15,000 pieces of pre-bundled mail, which he brought back, sorted, and, using a wheeled cart, delivered to the building’s three floors of offices. Stephanie Dailey, a young woman with a desk near the mail room, often helped him when she wasn’t busy opening mail for the National Enquirer. Ernesto never minded doing the work himself. Every morning he took the train from North Miami to Boca, eager to start his work day, sorry when it was done. All his life he’d been like that — full of energy, never missing a day of work. Six years before, thinking it was time for retirement, he’d sold his small upholstery business in Miami — and almost immediately grew bored. “AMI saved my life,” he often said. “Hanging around the house, doing nothing, that was driving me crazy.”

The year before, Bob Stevens had also tried retirement. After nearly thirty years of rushing to meet deadlines, he thought he’d like a life of biking, fishing, and gardening. He and Maureen, a retired secretary, could finally travel. but like Blanco, he missed work, and he missed his friends at AMI, a company that prided itself on a family-like atmosphere. In six months, he was back at his desk, editing photos of celebrity newsmakers.

As planned, early on Thursday, September 27, Bob and Maureen Stevens left for North Carolina. Robert (as his wife preferred to call him) loved driving and was in a great mood. Maureen, who was recovering from a sinus infection and taking the antibiotic Ciprofloxacin (Cipro), counted on his enthusiasm. they both missed having Casey at home. As they traveled north, they talked and laughed and made plans to celebrate their twenty-seventh wedding anniversary, which was coming up on October 18.

The next day, Friday, after Ernesto Blanco finished sorting the mail at AMI, he felt weak and feverish and was shivering like never before in his life. Concerned, Daniel Rotstein, the personnel director, arranged for a company driver to take the older man home to North Miami. On Saturday Blanco felt better but bewildered and a bit embarrassed. He’d always prided himself on his iron constitution, and now his wife, along with his stepdaughter and her husband, were hovering over him. On Sunday, the feeling of weakness returned, this time with chest pains.

Up in North Carolina, on the Sunday drive from Chapel Hill to Durham, flulike symptoms of weakness, fever, and chills hit Bob Stevens like a blow. He crawled into the backseat, letting Maureen take the wheel. On the highway, they kept passing exit signs for local hospitals; Bob adamantly refused to stop for help. After a few hours of rest at Casey’s boyfriend’s apartment, he felt much better. On Monday morning, he and his wife set off on the return trip to Florida. Bob, although quieter than usual, drove the whole way. they made it home at around 5 p.m., and tired, went to bed at eight.

That same Monday, Ernesto Blanco was admitted to Cedars Hospital in North Miami. His physician there, Carlos Omenaca, was baffled by his condition, which at first seemed like a heart attack. Blanco had some sort of infection, but what was it? Omenaca tried different combinations of intravenous antibiotics, but the weakness and chest pains persisted. Prostrate, Blanco listened to the bedside discussion of his mystery illness. “My father thinks it’s from an animal,” Dr. Omenaca remarked. “He used to be a farmer.” Those were the last words that Blanco remembered hearing before he slipped into a coma.

At 1 a.m. on Tuesday, Maureen Stevens woke to the sound of her husband retching in the bathroom. He was fully dressed and this time, dizzy and weak, he made no objection when Maureen insisted on driving him to the John F. Kennedy Medical Center (JFK) in nearby Atlantis, just five minutes away. Bob had been a patient there before for minor heart problems, and his daughter Heidi had a job in the hospital’s administration. Once checked in, Stevens was given a bed to lie down on and, to calm his nausea, a sedative. then he fell unconscious and, with his vital signs failing, was transferred to intensive care.

A physical examination and routine tests shed no light on Stevens’ sudden collapse — it wasn’t a heart attack or stroke or pneumonia or trauma from a fall. Maureen took the attitude that no news was good news. Around 5 a.m. she went home to sleep and returned promptly at eight for Robert’s scheduled spinal tap. she and Heidi watched in anguish as, still unconscious, he struggled against the painful procedure.

Larry Bush, the hospital’s chief of infectious diseases, knew that otherwise healthy adults don’t suddenly collapse without cause. a transplant from the urban Northeast, he focused on the clouds, letting others search for silver linings. In his field, his pessimism had yet to let him down. Attuned to the bioterrorism threat, he had in his office a well-read copy of a 1999 article on anthrax as a biological weapon, co-authored by USAMRIID’s Art Friedlander and a group put together by the Johns Hopkins Center for Civilian Biodefense Studies. When Bush examined Stevens’ spinal fluid under a microscope, he found in it a proliferation of rod-shaped bacteria, like jumbled chains of bamboo, certainly a type of bacillus. Bush ran a simple test and discovered that the bacteria were “gram positive,” one of the characteristics of Bacillus anthracis. to be sure, Bush needed more sophisticated tests, the kind that, according to protocol, should be done at the Florida Department of Health laboratory in Jacksonville, which was part of the Laboratory Response Network created under the Clinton administration. for this he needed an assist from a public health official.

Bush telephoned someone he knew on a first-name basis: Dr. Jean Malecki, head of the Palm Beach County Public Health Department. nearly twenty years before, Malecki had been his colleague at JFK, when both were newly minted infectious disease specialists, he from the University of Pennsylvania, she from New York University.

The dynamic Malecki, six feet tall with long red hair, was already a local legend. In the public eye for nearly twenty years, starting with the early 1980s AIDS fatalities linked to a Florida dentist, and through dozens of high-profile incidents since then, she was in charge of the health of two million county residents and she counted them all as her people. with Florida on alert after 9/11, she had convened a meeting of 200 first responders to assess the potential bioterrorism threat. at 2:15 p.m., when Bush’s call was forwarded to her, a panel of experts had just finished discussing whether terrorists could effectively use a crop duster to spray anthrax spores. In Florida, the front-page news, based on FBI reports, was that before 9/11 al Qaeda operatives had circulated under cover in Palm Beach, Delray, Venice, Hollywood, and Jacksonville and that, while taking flying lessons, they had inquired about crop dusters.

Advising Malecki to sit down, Bush explained that he had a patient who might have inhalation anthrax and asked her how soon she could come to the hospital to give her evaluation. The patient had presented as a meningitis case, with signs of general acute infection, but Malecki trusted Bush’s judgment. Tied up with her meeting on domestic preparedness, she told him that the best she could do was seven that evening. The patient’s history of possible exposure would be vital, but with Stevens in a coma Malecki would have to get the details from his wife. “I’ll have my staff bring an anthrax questionnaire,” she told Bush.

Public health professionals work in essentially two modalities. One is routine preventive management — making sure schoolchildren have their vaccinations, pregnant women their vitamins, and old people their flu shots, and that chronic and infectious disease incidents are monitored. The other is emergency mode, the team mobilization to contain disasters that is the equivalent of marshaling troops for war. a seasoned administrator, Malecki handled the former every day, but she was no stranger to real-life emergencies or mass attack models. In the late 1990s Malecki had participated in two exercises for responding to mass anthrax attacks that pushed the emergency response model beyond the envelope — which was exactly where Bush’s patient, if this were the index case of a larger outbreak, might be heading. The exercises were designed to teach local authorities — herself, hospital officials, police, firefighters, and the WMD experts from FBI field offices — in fact, the very people at her meeting — to make rational decisions that would, if the threat were real, trigger state and federal government rescue responses. The effect should be like a computer game in which communication channels light up, the troops arrive with medical supplies, and hundreds if not thousands of lives are saved from deadly anthrax.

Throughout the response, public health officials had to stay calm and keep the affected community informed, cooperative, and free from panic, or the rescue effort could fall apart. since 9/11, though, the public was primed for panic, and anthrax and other disease attacks were being touted widely in the media as the next worst terrorism.

Bush’s phone call left Malecki with some troubling uncertainties. The minute she asked Jacksonville to test for anthrax, alarms would ring in government offices from Florida to Washington. if the results were positive, louder alarms would ring and the media would be all over the story, no matter how the man at JFK had been exposed. Malecki had spent years cultivating good relations with the press. Did she have enough capital with them to keep communication focused on education and not scare-mongering headlines?

Unfortunately, fear of anthrax was hardly irrational. Its ferocious natural cycle uses the host mammal as a live incubator that must die for B. anthracis to multiply and survive. within the host’s body, the proliferating bacteria rapidly cause massive internal hemorrhage so that, bursting from every orifice in waves of blood and fluid, this new generation of microbes can assume their sturdy spore form and await a new host to infect. As the disease evolved over many centuries, a grazing animal feeding in a spore-contaminated field was usually the next victim. By learning to live successfully off livestock, human beings became potential hosts. When twentieth-century armies developed B. anthracis as a weapon, the potential for the human host population expanded to mass targets, not what nature intended.

Another uncertainty was how federal agencies would react, even to a single confirmed anthrax case. State health officials in Tallahassee would have to invite the CDC (Centers for Disease Control and Prevention in Atlanta) to investigate: anthrax was not endemic in Florida and the last U.S. case of inhalational anthrax dated back thirty years. if evidence pointed to an intentional cause — an act of malice against a single individual, or worse, a mass attack — the FBI would step in as the lead agency to conduct a criminal investigation. if more cases of illness emerged, beyond what Malecki’s department, the state, and the CDC could handle, Washington would send the Federal Emergency Management Agency to coordinate a disaster response. Malecki hoped that Bush was sounding a false alarm. Whatever had happened or would happen, she had to stay calm.

When Malecki arrived at the hospital that evening, Bush led her to his patient’s room. “I’ve put him in isolation,” he explained, “and he’s on broad-spectrum antibiotics.” they put on masks and gloves before they entered.

Stevens lay on the narrow bed in a coma, attached to a respirator and an array of drip bags and monitors. He was a big man, husky but muscular. His wife, Maureen, also masked and gloved, sat next to him holding his hand. When Maureen Stevens stood, the look she gave Dr. Malecki was more inquisitive than worried. no one had mentioned the possibility of anthrax in order not to upset her unnecessarily. instead, Dr. Bush had told her that her husband had a general infection, meningitis, that was affecting his brain and that more tests had to be done. While Maureen waited, she wanted to stay at her husband’s side in case he should wake, but she understood that the county health department had some questions for her and that its director, Dr. Malecki, was here to help.

Three of Malecki’s assistants then met with Maureen in a small conference room. they had written the questionnaire themselves, on the fly, after finding nothing available from the CDC. In her soft, precise Irish accent, Maureen gave them a detailed account of the trip to North Carolina and described her husband’s everyday routine and his hobbies. she answered every question, even the odd ones. Yes, she kept a clean house and frequently laundered their clothes, sometimes daily. no, they had not been at any country fairs or crowded events. Yes, he liked genuine leather shoes. no, as far as she knew, he didn’t handle mail at work.

She had no idea how these questions could help her husband’s diagnosis, but realizing these officials were nearly as puzzled as she was, Maureen summoned new energy and told them everything she could remember, including how on their hike Robert had stopped to drink from a mountain stream, which he (unlike Maureen and Casey) trusted was unpolluted.

After going over Stevens’ case records and viewing the bacilli from his spinal fluid, Malecki reached the same startling conclusion as Bush: the patient was likely infected with anthrax. By 10 p.m., a sample of the bacteria from the spinal tap was on its way by express mail to the Jacksonville laboratory. Phil Lee, one of the lab’s microbiologists and its biological defense coordinator, had recently returned from a course on anthrax analysis at the CDC, given by Tanja Popovic, head of the CDC’s Anthrax Laboratory, with an unrivaled reputation for B. anthracis identification. In 1989, Popovic had come to the CDC as a Fulbright scholar from Croatia and found her niche in the lab science of domestic preparedness. By October 2001, she had trained sixty public health employees like Lee to recognize anthrax in their own laboratories, all part of the nation’s Laboratory Response Network.

As Malecki expected, her Tuesday night request to Jacksonville rang alarm bells. When her office opened the next morning, two FBI agents were waiting for a transcript of Maureen Stevens’ interview, which Malecki’s staff, having worked through the night, had ready by 10 a.m. The interview, with Malecki joining in, had lasted until nearly eleven the night before. Maureen Stevens would have stayed even later, if asked. As one interviewer reflected, her narrative, with all its careful detail, was “a love story” told by a wife who wanted her husband brought back to health, to her. In addition, Malecki alerted Steve Wiersma, the state epidemiologist, and John Ogwunobi, the young pediatrician who had just assumed the post of Florida’s secretary of health.

At the Jacksonville lab, Phil Lee proceeded with the first and then the second of the tests he’d learned at the CDC. Both involved growing and staining the bacteria to elicit an important identifying trait: dangerous anthrax bacilli are distinguished by a capsule, a casing essential for virulence. The third and most conclusive test, which had been developed at USAMRIID, involved exposing the bacilli to a virus called gamma phage that would invade and destroy them if they were truly B. anthracis. By late afternoon, the first two tests had registered positive — the distinguishing capsule was present. Larry Bush called for the results, but Lee was reluctant to draw a definitive conclusion. The third test had just been started and could take twelve hours or more. Lee, to make sure he was doing everything right, contacted Tanja Popovic at the CDC, who calmed his apprehensions. As far as she could tell, Lee was being meticulous and should reach a valid diagnosis.

In Palm Beach, awaiting Lee’s results, Malecki began planning a three-team public health investigation to determine the source of Stevens’ infection — strictly by the book. One team would search the Stevens house and garden, another would track possible exposure sources outside the home, and a third would investigate his workplace, the AMI building. Stevens’ recent trip to North Carolina meant that public health officials there might have to check with hospitals for any suspicious meningitis cases and with veterinarians for any unusual livestock or other animal deaths. a visit to Casey Stevens’ apartment and that of her boyfriend — where Bob had taken a nap — would also be necessary. As a precaution, Malecki telephoned AMI in Boca Raton with the message that if any other employees had an unusual illness or skin infection, they should call her department right away.

Lee left his laboratory at 10 p.m., with no result yet from the gamma phage test. When Bush called the next morning around eight, the result was in, but Lee, knowing the fallout was going to be calamitous, hesitated to tell Bush about it. Irate, Bush reminded him that it was his patient whose life was at stake. Lee then revealed that the gamma phage had destroyed the bacilli: Bob Stevens had anthrax.

The news went immediately to Tallahassee and John Ogwunobi, who brought the news to Governor Jeb Bush. Once he was updated, the governor had one question: “Is the disease contagious?” His foremost interest was in keeping the public panic level down. since 9/11, he had been focused on protecting potential terrorist targets in Florida — Cape Canaveral and Disney World were two of them — while at the same time worrying about the precipitous drop in tourism to the state. People were afraid to fly, which could spell disaster for Florida’s winter economy. Tourists would be even more likely to stay away if Florida were hit by a contagious disease outbreak, especially if it were intentionally spread. to the governor’s relief, there was no cause to worry about contagion — and the single case in Lantana might have been naturally caused.

At the JFK Medical Center, Larry Bush consulted with hospital administrators and his staff about what steps to take next. Not only the governor’s office, but the White House, cabinet secretaries, the National Security Council, and a network of federal counter-terrorism officials were being alerted to the diagnosis, which could signal the start of a mass attack — or nothing more than an isolated infection. In reaction to rumors, media inquiries had already started. The decision was to hold a press conference that afternoon, at the hospital, to make an official announcement.

In all the excitement, no one had told Maureen Stevens about her husband’s diagnosis. at noon, she left his bedside to pick up photographs from their North Carolina trip, as reminders to talk about with Robert. she and Heidi acted on the presumption that, although unconscious, he could still hear their voices and that they needed to stay connected with him. After picking up the photos Maureen made a brief stop at home. As the news of Bob’s hospitalization spread, the answering machine became full of get-well messages from friends and co-workers and, despite the heat, a kind neighbor had volunteered to mow the lawn. Maureen was in the kitchen when Dr. Malecki telephoned.

“I have some difficult news for you,” she said. Malecki then explained that Bob had contracted a disease called inhalational anthrax. she cautioned that his chances of survival were not good. The infection had been treated late, after it had spread.

“Is there no hope?” Maureen asked. she remembered the hospital exit signs between Charlotte and Durham — and Robert’s refusal to stop.

“There’s always hope,” Malecki assured her, sparing Maureen the facts about the ferocity of the disease. then she added that word of the diagnosis had necessarily spread and would soon become public. “There’s a press conference scheduled for two o’clock at the hospital.”

As soon as she hung up the phone, Maureen began contacting the children. she called Casey in North Carolina, who immediately made arrangements to take the next plane home. Maureen reached Heidi at JFK, just minutes before a senior administrator took her aside to tell her about her father’s diagnosis. Bob’s son Neil was already driving down from Tallahassee, where he lived, and Maureen’s daughter Tania was arriving the next evening from Scotland. still in her kitchen, Maureen telephoned the news to Daniel Rotstein, the AMI personnel director who had been in close touch with her since Bob had fallen ill. He was shocked and then he suddenly apologized. “Maureen, I’ll call you back. There’s something important I have to do right away.”

That something important was to find out what had happened to Ernesto Blanco, who had yet to return to work. When Rotstein learned he was at Cedars Hospital, he tried to reach his physician there but couldn’t get through. might Blanco have the same disease as Bob Stevens? The implications for the company and other employees in Boca could be terrible.

Just before the press conference at JFK, Larry Bush met with Maureen Stevens to explain the anthrax diagnosis and that this particular disease was not contagious. Maureen didn’t recognize most of the other people gathered around them, except for some hospital staff. Events were moving faster than she could comprehend. she had just one question for Dr. Bush: “Is my husband going to die?”

Bush repeated what Malecki had said, that when treated late in its course inhalation anthrax is nearly always fatal. but, like Malecki, he told her there was always hope. Just the idea of hope gave her strength and calmed her.

But then, abruptly, Maureen was forced to confront the possibility that her husband had been deliberately attacked. she signed one form permitting the FBI to search the Stevens home and property the next day. she signed another form given her by officials from the Atlanta office of the Postal Inspection Service, the plainclothes criminal investigation division of the U.S. Postal Service. that signed form gave the postal inspectors the right to appropriate and examine the family’s mail. perhaps, they explained, someone had personally targeted her husband by sending an envelope or package with anthrax powder in it. another postal attack might be coming — a frightening thought. a Miami FBI agent was detailed to watch over her. it was dawning on Maureen that the news about her husband’s diagnosis had been passed along to strangers — to hospital officials, the FBI, postal investigators, even to the governor of Florida and the president of the United States — without her knowing anything.

Thinking only of her husband, she hurried to the new room where he was sequestered under guard, surrounded by even more medical equipment and nurses. with no threat of contagion, the masks and gloves were no longer necessary. Afraid of losing him, she stroked his forehead, and whispered words of comfort.

The press conference was held on the first floor of the hospital, off the lobby in the conference room usually used for medical lectures, and at least fifty news representatives from local and national print, radio, and television outlets jockeyed to get near the speakers. State epidemiologist Steve Wiersma had arrived from Tallahassee. Jean Malecki was by far most familiar to the Florida press, but the star of the event was Larry Bush, who had flagged a case that other physicians might have misdiagnosed or dismissed as a medical mystery.

Privately, Bush believed the maxim expressed in the 1999 Johns Hopkins article on anthrax, that any new anthrax case should be presumed intentional until proven otherwise. but he, Malecki, and hospital officials agreed beforehand to make no speculations about how Stevens had contracted anthrax and certainly not to promote the idea that the case had anything to do with a bioterror attack. instead, they announced that an unnamed hospital patient had contracted inhalational anthrax, a diagnosis confirmed by the Florida Department of Health Bureau of Laboratories, and they described how medical tests supported this diagnosis. By way of instruction, they presented a recent x-ray showing unusual mediastinal widening — an enlargement in the midchest area often characteristic of this form of the disease. about his patient, Dr. Bush commented dispassionately, “He is critically ill, but hopefully he’ll respond to treatment.”

The sensational news of the Florida diagnosis went out immediately on the wire services, sparking national attention. In Washington, Tommy Thompson, secretary of Health and Human Services, interrupted a White House press conference to announce the news, but he too insisted, “This incident has nothing to do with terrorism.”

Behind the scenes, President Bush was worried that the Florida case was the first sign of a mass attack. since 9/11, the president had been taking Cipro, on the advice of a federal consultant on bioterrorism threats. President Clinton’s dread of an apocalyptic outbreak intentionally inflicted on Americans was based on nightmarish conjectures. for Bush, the Stevens diagnosis and its implications crossed the line to the fact of an anthrax infection and a possible “second blow” struck against the nation. As the United States moved closer to attacking the Taliban in Afghanistan — the first missile assault was only days away — there were fears in the administration that al Qaeda would retaliate with bioterrorism. Vice President Cheney, officially in seclusion as tension mounted, was anxious about both germ and chemical terrorism. After 9/11, he kept a gas mask and protective clothing within easy reach and he was nearly always accompanied by a physician.

From Florida’s capital, the call for assistance went to the CDC, which was at some disadvantage. The 9/11 attacks had diverted some one hundred of its field officers to New York City and exhausted them with the extraordinary public health demands of a traumatized city. The CDC’s usual mission was the statistical documentation and prevention of the nation’s everyday health care problems, which ran to chronic diseases like heart and kidney ailments and cancers common in industrialized nations with older populations. it was only late in the Clinton administration that the centers were put in charge of the nationwide domestic preparedness program and of organizing the national Laboratory Response Network and the stockpile of emergency antibiotics and vaccines. at the CDC’s National Center for Infectious Diseases, its director, Jim Hughes, had a global perspective on disease prevention, and its acting deputy director, Julie Gerberding, came from a background in hospital and health care safety. given the rarity of anthrax cases — only eighteen in the United States in the previous hundred years — there was no expert with field experience who understood dose response and the random risk of even a single inhaled spore. a retired CDC officer, Phil Brachman, had conducted studies of inhalational anthrax cases among American textile and tannery workers in the 1950s and 1960s. but Brachman’s research, done with U.S. Army cooperation, had been neglected by the younger generation of epidemiologists focused on contemporary plagues: AIDS, malaria, cholera, drug-resistant tuberculosis, and other dangerous diseases. Not even the 1994 publication of the Sverdlovsk investigation results and their implications for dose response were well known among CDC infectious disease experts. By far the person in the strongest position was Tanja Popovic, the head of the Anthrax Laboratory, with a staff of forty-three and expertise to spare. but at the time not even she understood the enormous difference between preparing for bioterrorism and the emergence of an actual case of deliberately caused anthrax.

The Stevens diagnosis also rang alarms at the FBI, which had intensely combed Florida, including Lantana, for the pre-9/11 presence of al Qaeda operatives. at its Quantico, Virginia, campus, the Bureau’s WMD division had spent years tracking international and home-grown terrorists. there chemist Benjamin Garrett had long studied biological and chemical weapons history, as well as handled the strange cases — like the 1984 poisoning of salad bars with salmonella by the Rajneesh cult in Oregon — that came with the chem-bio watch. After 9/11, Garrett’s division was on high alert for another al Qaeda attack, as was the Bureau’s Hazardous Material Response Unit (HMRU), also at Quantico, where microbiologist Doug Beecher, experienced in pathogen detection, worked. these and other experts, a veritable brain trust, would prove key in responding to the Florida and subsequent crises. but on October 4, the Bureau, concentrating fully on its 9/11 investigation and unsure if a crime had actually been committed, delayed coordinating a top-down response.

Still, the FBI had the flexibility of a large, decentralized organization whose field agents could be locally deployed. Two of them quickly drove from Jacksonville to Atlanta to deliver a sample of Stevens’ bacteria to Tanja Popovic so that she could verify Lee’s results at the CDC’s Anthrax Laboratory. Carefully growing the bacilli in culture medium (which could take another day or more) was essential to accurate identification at the CDC’s gold standard level.

The missing clue was strain identification: which of the forty or so known virulent anthrax strains had infected this patient in Florida? The Quantico brain trust turned immediately to Paul Keim, the Northern Arizona University scientist who had developed advanced methods for genetic strain identification and maintained a considerable archive of strains. Doug Beecher telephoned Keim to give him a heads-up. Beecher, experienced in hazardous material response, had previously visited Keim’s lab and understood the science of B. anthracis. The message from Beecher to Keim was that a share of the CDC sample was being flown by a chartered plane to Flagstaff, where Keim himself should collect it for analysis.

Until 9/11, when his university put his lab under strict protective security, Keim’s work life had been placidly academic, with a mix of intriguing microbial projects, not just ones on anthrax. Lanky and sandy-haired, Keim looked more like a graduate student than a professor. Late in the afternoon on October 4, though, Keim was about to enter the world of crime scene investigation. He drove out onto the tarmac at the Flagstaff airport to meet the chartered plane, from which descended an attractive blond woman who handed him the box containing the bacteria from Stevens’ spinal fluid. Speeding back to his laboratory, Keim organized his assistants to begin the process of matching its genetic markers against those in his archive of anthrax strains from around the world.

At the U.S. Army Medical Institute for Infectious Diseases (USAMRIID) at Fort Detrick in Frederick, Maryland, the news of the Florida diagnosis sparked interest but caused no shock waves. The case, after all, was a civilian matter, unlike the analyses of air samples from the Pentagon that USAMRIID’s Special Pathogen lab, run by John Ezzell, had just finished.

Bruce Ivins, angry and withdrawn after the 9/11 attacks, seemed energized by the October 4 news of the Florida diagnosis. that afternoon and into the next morning, he fired off emails to colleagues to offer his ideas about the source of the exposure, which he theorized was natural, somehow from the environment. although unaware of Beecher’s recruitment of Paul Keim, he knew about the Anthrax Laboratory at the CDC. (His friend Ezzell had actually been there on 9/11, and was evacuated with everyone else from the CDC’s main campus.) Ivins posted an email to the centers, to ask a perceptive question: Had its experts identified the strain and did they know if it was native to Florida? In fact, Tanja Popovic at the CDC was trying to identify the strain at the same time as Paul Keim.

But no return message was sent to Ivins. Even if the CDC hadn’t been deluged with emails, Ivins’ inquiry would have gone unanswered. Popovic understood that the Stevens diagnosis could embroil her and her bosses in a major bioterrorism incident — and that national security necessarily narrowed channels of communication.

That evening, Bob Stevens’ wife, his son, and his two daughters surrounded him with affection, taking turns holding his hands and keeping up a conversation about good times past and good times to come. Heidi went home early to her family. Later, near midnight, the rest of the Stevens family — Maureen, Neil, and Casey — wished Bob good night. As they reached the lobby, what seemed like a SWAT team burst through the main doors, backlit by klieg lights from the camera crews still waiting outside. it was a mixed group of county public health officers and FBI agents with a hurried request for blood samples from Maureen and Casey. The two were tired but consented. When the procedures were done, they dashed past the press lingering in the parking lot.

Arriving home, they found that a media blitz was waiting for them. Vans with satellite dishes were parked on both sides of the narrow street. In the glare of spotlights, reporters crowded the newly mowed front lawn. with microphones in hand, news anchors talked nonstop to cameras about their on-site coverage of the Stevens case. a swarm of reporters and photographers, avid for news about the victim, attempted to interview the family members as they ran for cover. The brightly lit, noisy broadcasts continued for hours. Finally, to block the lights, the Stevens family hung blankets and sheets over the windows.

While the Stevens family tried to sleep, Paul Keim and his team worked through the night to identify the Florida anthrax bacteria. In the early morning, they finally matched them to the highly virulent Ames strain. The name, as they found out later, was a misnomer. The strain, from a Beefmaster heifer that died in Texas in 1981, had been shipped to USAMRIID with an envelope that bore the return address of Ames, Iowa. Iowa had nothing to do with the strain’s origin, but the mistaken attribution stuck.

From his lab, Keim telephoned the news to the FBI and the Department of Energy (his two main funders) and then to the CDC. that same day, Friday, October 5, at the CDC, Tanja Popovic corroborated Keim’s discovery.

For Doug Beecher and others at the FBI in Quantico, the strain identification was a game changer: the Florida inquiry stopped being a public health inquiry and became a criminal investigation, one with heavy national security implications. The Ames strain, found once in nature and never again, was currently used in defense research laboratories for testing vaccines and antibiotics and other protective interventions. The defense laboratories that possessed the Ames strain — whether government labs or private contractors, whether in the United States or in allied countries — would have to be determined. since the intelligence community was engaged in anthrax research projects, the Bureau might hit what policy analysts called “the wall” — the separation between criminal investigation and intelligence activity that divided the internal organization of the FBI and blocked communication between the Bureau and the CIA.

There was another, worse problem. According to Keim — and this was well known among anthrax researchers — the Ames strain, like other strains of anthrax, was so genetically conservative that it would be unlikely to vary in successive generations or from one laboratory sample to another. that is, it was fundamentally generic. The anthrax weapon was identified, but it no more had a distinct signature than a bottle of Tylenol pills. When a weapon was that generic, the criminal might never be found.

Excerpted from American Anthrax: Fear, Crime, and the Investigation of the Nation’s Deadliest Bioterror Attack by Jeanne Guillemin. Copyright 2011 by Jeanne Guillemin. Excerpted by permission of Times Books. All rights reserved.

The associated Press

Date: Monday Sep. 12, 2011 8:07 PM ET

PORT-AU-PRINCE, Haiti — a U.S.-based health group in Haiti says it saw a huge drop in the number of patients seeking treatment for cholera in the Caribbean country.

Partners in Health says the number of hospitalizations fell by 57 per cent at its 15 cholera treatment centres from July to August. The drop mirrors the caseload doctors saw before the spring rainy season.

But the group was still concerned about cholera. Partners in Health said the 5,400 hospitalizations in August are a reminder that cholera will be in Haiti for the foreseeable future.

The findings were released Monday.

Haiti’s Health Ministry says cholera has killed more than 6,200 people and sickened almost 440,000 others. a U.N. battalion from Nepal has been blamed for introducing the disease to Haiti.