Chasing the Ghost

Doctors and scientists race to unlock the deadly mysteries of Covid-19, while local survivors share their stories. Plus: a summary of the world’s worst pandemics.

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On April 4, 2020, Rev. John Wilkins fell out of his truck. Wilkins is pastor of Hunter’s Chapel Church in Como, Mississippi, and world-renowned for his mix of gospel, blues, and soul music. The 75-year-old didn’t think much of the fall, other than as a normal hazard of North Mississippi farm life. But days later, he was not feeling better. His family convinced him to go to Baptist Memorial Hospital – Desoto to get checked out, but his daughter was not allowed to come in with him.

“I called them, and told them they were going to keep me,” he says. “And that’s all I remember. I had that virus, pneumonia, and everything.”

Wilkins was one of millions of people around the world who have become infected with the novel coronavirus which scientists call SARS-CoV-2 (severe acute respiratory syndrome coronavirus). The disease the virus causes is known as covid-19 — the ‘19’ indicating this virus’s first emergence, in 2019.

Dr. Stephen Threlkeld is the medical director for infectious disease at Baptist Memorial Health Care and a third-generation Memphis doctor. He has been on the medical frontlines since the beginning of the pandemic. Threlkeld says SARS-CoV-2 is unlike any virus he has ever encountered.

“It approaches uniquely in both the widespread array of symptoms that it can cause, and also in its incredible variability of how it affects people,” he says. “We can certainly say that the elderly are heavily affected. Obesity seems to be a strong risk factor, and heart problems certainly seem to be important. But I can assure you that we have people in their twenties, thirties, forties, and fifties who have been critically ill. Many times we can’t really find a classic risk factor. Its ability to pick and choose who it is going to make seriously ill is, I think, unsurpassed, and unlike anything I’ve ever seen.”

In late May, Leslie K. Nelson had a friend who seemed perfectly healthy sleep on her couch for a night. On June 1st, the friend was treated for what they believed was heatstroke. It was covid-19. Nelson herself started to feel sick on June 8th. Three days later, she was admitted to the hospital.

“I called because I couldn’t breathe,” she says. “I was coughing, constant migraine, hot, sweaty, hurting all over. I could not focus at all.” 

There are many different types of coronaviruses, which are so named because, when viewed by an electron microscope, they resemble the sun’s corona. Some well-known coronaviruses cause the common cold, spread by droplets of moisture and saliva expelled from the nose and mouth. “You sneeze in your hands, then you shake hands with someone else,” says Threlkeld. “They touch their face without washing their hands. That’s our experience with a lot of respiratory viruses. And so, [with covid-19] there was no reason to assume otherwise.”

Multiple studies had found that droplets containing viable virus particles couldn’t travel through the air more than six feet — hence the need for “social distancing.” But as scientists traced patients’ contacts and conducted tests on smaller, “aerosolized” droplets, Threlkeld says “circumstantial evidence began to arise that people were getting this from a little farther away from one another, and without touching things.”

The conclusion was startling. Instead of falling quickly to the floor, it seemed that viral particles riding on aerosolized droplets could linger in the air, especially after being expelled forcefully from the mouth of an infected person. Inhaling just a few of those tiny particles probably won’t result in an infection. But in a confined, poorly ventilated space, the droplets can create an invisible cloud containing a large enough viral load to cause illness.

The original SARS-CoV, which caused a 2003 epidemic of respiratory disease in Asia, was only transmitted by people who were exhibiting symptoms. Early in the current pandemic, doctors posited SARS-CoV-2 would be similar. It is not. covid-19 patients can be infectious up to 48 hours before they develop a fever, cough, or chills. And a significant percentage of people infected with the virus never show any symptoms at all.

Threlkeld says this is a nightmare scenario. “Asymptomatic and pre-symptomatic transmission is a very important characteristic of this infection that has really kept us on our heels the entire time,” he says. “It’s very difficult to chase that ghost and do effective contact tracing if a lot of those contacts never got sick.”

If an infectious person spends time in a crowded space, like a bar or church, his or her presence can cause a “superspreader event.” Under normal circumstances, a covid-19 patient can be expected to infect one or two other people. In one well-documented superspreader event, a South Korean man visited three dance clubs in one night and infected 54 people.

“These large events are probably a very important piece in keeping the virus spreading in the community,” says Threlkeld. “A wedding where people come from out of town may generate 50 cases among them. And then each of those people goes back and might spread it within their home. So all of a sudden, you have brush fires that get out of control.”

For video producer Eric Swartz, the first inkling he was coming down with covid-19 was a chill in the night. “I blew it off, jumped under the covers, and got warm,” he says. “The next day, I just felt kinda off. I had a business meeting with someone, and of course I masked the whole time. The person I met with did not get sick.”

Early messaging about mask wearing was confusing. Epidemiologists with the Centers for Disease Control knew that conventional masks would not offer the wearer much protection against infection, so they initially did not recommend them. But once the possibility of asymptomatic and pre-symptomatic spread came to light, the equation reversed.

Masking protects the community more than the individual mask-wearer. Masks prevent droplets emerging from the mouth and nose from becoming airborne, greatly decreasing the possibility of transmission. And the simple measure turns out to be surprisingly effective. Widespread masking, combined with basic social distancing and regular hand-washing, could effectively prevent large-scale covid-19 outbreaks, even in the absence of a vaccine. “We need to keep all three of those elements on the front burner to combat this virus,” says Threlkeld, “And of course, for heaven’s sake, don’t go around other people if you are sick.”

When Swartz’s fever started to climb, his wife, Sarah Christine Bolton, decided to quarantine him in their bedroom. His shortness of breath got much worse. “I started feeling like any normal activity I would do, like just walking out to the garden, would leave me feeling exhausted,” he says. “I had a lot of work coming up that weekend, so I had to suddenly call and get somebody to cover my jobs. Even just thinking hard and trying to arrange that was exhausting. The other weird part about it was being quarantined in your own house, separate from everyone you’re normally with every day, and having food brought to the door and all that stuff. And of course, I was worried that I had already exposed them.”

So many people have so many different manifestations of this infection, it’s hard to lump those things into something that’s easily studied.” — Dr. Stephen Threlkeld

Threlkeld says the isolation of quarantine “adds a level of suffering to this infection that just makes it harder for everybody involved. It’s something that I think the average person out there who hasn’t experienced it in their family or in a close friend has a hard time really understanding.”

To alleviate the isolation, nurses have taken to arranging video calls between covid-19 patients and their relatives. Rev. Wilkins woke up after 17 days on an ICU ventilator, but he remained in the hospital for another month. His only contact with his daughters was through FaceTime. “That was a real blessing,” he says.

Despite their best efforts to prevent the virus from spreading in their home, Swartz, Bolton, and their two children all started showing symptoms of covid-19. But when the family was tested, only their daughter’s test came back positive. “At that point they told us, well, because she’s positive, and you’ve all had the same symptoms, we just assume that you all have it,” says Bolton. “For whatever reason, I think the tests are kind of persnickety.”

Threlkeld says the nasal swab test commonly administered at testing centers is designed to detect the presence of viral RNA. “You can largely trust a positive test, but a negative test is very problematic,” he says. “If you have a hundred people with the infection, it may miss 20 to 30 of those people. And consequently, we still have to go with our clinical impression when we evaluate people. A colleague of mine clearly had the infection — and upon further, more sophisticated testing, was shown to have the infection — but he had three separate, well-performed, appropriate nasal swabs that were all negative.”

How did that happen? “I do not know, but the test is far from perfect at finding everybody out there with the infection,” says Threlkeld. “So if I see someone who has lost their sense of taste and smell, and who has a cough and shortness of breath, I am not going to send that person back to work. I think at that point, the clinical impression becomes better than the test in your hand.”

Leslie K. Nelson spent eight days in the hospital before being sent home to make room for other patients, once her doctors thought she was on the road to recovery. But Nelson turned out to be a “long-hauler.” Her illness ebbed and returned over the course of months. “Symptoms develop at different times, even new ones, like tendinitis and ringing in my ears,” she says. “My taste never totally went away. It changed, got weird. Some things got really awful. Chocolate tasted like oil.”

The long-term effects of covid-19 are only now beginning to be understood, says Threlkeld. “A lot of times, those situations turn into three or four things. Some of them are people who had a severe infection and may have some leftover lung damage. That certainly happens not just with SARS-CoV-2, but with other things as well. There are some unusual symptoms that we do not fully understand yet. Some of the patients I’ve taken care of with this infection have had, for example, neuropathy — painful burning in the legs. We don’t have an explanation for it. How long will it last? We don’t know.”

Threlkeld also mentions “sort of a brain fog that people tend to have after this infection. A couple of my physician friends have described that fairly heavily. They have to think harder about something than they’re used to, and things don’t come as easily to them. We hope those things will be short-lived, but there are any number of things out there that people are complaining of for a longer period of time. So I think there are probably several factors that come into play as to why that happens. So many people have so many different manifestations of this infection, it’s hard to lump those things into something that’s easily studied.”

Truck driver Christopher “Bootsie” Duebner started to feel ill in a Kentucky hotel room. The 27-year-old Memphian thought it might be covid-19, so he returned home and quarantined himself. Duebner’s longtime neighbor Eileen Knoblock says Duebner was a normal, healthy guy. “He doesn’t smoke, he doesn’t drink to excess by any definition,” she says. “He doesn’t do drugs. My son talked to him on Thursday, and asked if he needed any food or anything, offered to drop it off on the porch. He said no, he had everything he needed. Then on Saturday, he got worse, and his girlfriend took him to the hospital. They put him on oxygen. Then on Sunday, my son told me they were going to put him on a respirator. He looked at me and said, ‘Mom, Bootsie’s healthy.’ I didn’t want to say anything, but I knew it wasn’t going to be good.”

By Tuesday, Duebner’s kidneys were failing. “The next night he died,” Knoblock says. “It’s like a slap in the face. How can he be so alive, and so full of life, and then he’s just gone?”

Many young people with strong immune systems think they have nothing to fear from the virus. “The immune system is a great thing, but it sometimes doesn’t know when to quit,” says Threlkeld, describing the phenomenon known as a cytokine storm. “The problem is, sometimes when you get the infection, there are a couple of stages. After seven days or so with headache, maybe a cough, maybe a fever and other symptoms, sometimes the immune system just jumps out of control and, in an attempt to kill the virus, severely damages our lungs, and sometimes other parts of the body, by mistake.”

Threlkeld is encouraged by the rate of scientific advances providing new tools to fight the virus. Vaccine research appears to be progressing quickly, but it could still be a year before an effective product could be distributed. Another promising technique involves isolating and cloning antibodies from patients who have recovered from the disease. “This is a technology that is changing the face of medicine,” says Threlkeld. “For us to be able to get a good antibody that will attack this virus is potentially a big gain for us moving forward. It could a whole lot more effective than anything we have now.”

In the meantime, Threlkeld continues to emphasize how important it is for everyone to wear a mask, practice social distancing, and wash their hands: “When you start talking about having this virus run roughshod through our entire nation, it would certainly be a death toll like nothing we’ve seen in our lifetimes.”

Epidemics Through The Ages

In a sense, we’re lucky. The triumph of hygiene and modern medicine has greatly reduced the threat of viral and bacterial transmitted disease. Very few Americans alive today have ever had the experience of living through a true pandemic. But for most of human history, we have been stalked by deadly disease, and occasionally an outbreak spins out of control.

The Plague of Athens (430 BCE)

While some Sanskrit scholars have found references to influenza outbreaks in Babylon more than 3,000 years ago, the first well-documented epidemic was the Plague of Athens. Thucydides’ account in his History of the Peloponnesian War has elements that sound familiar today. Athens, a cosmopolitan port city and early model of democracy, was embroiled in a long-simmering war with Sparta when a mysterious disease emerged from far-off Ethiopia. The plague, which announced itself with a sudden fever and sore throat, tore through a population swollen with soldiers and refugees. Physicians who tried to comfort the sick were among the first victims. More than 100,000 died within the Long Walls of Athens. Spartan troops retreated from the siege after seeing piles of burning dead. Thucydides believed that the large number of sailors who died of the disease was enough to tip the balance of the war against Athens. The true nature of the disease which changed the course of ancient history remains unknown.

The Plague of Justinian (541-549 CE)

It had been a rough century for the Roman Empire, but things were looking up until the plague arrived. The Plague of Justinian, named for the emperor who contracted the disease in 542, killed about 20 percent of Constantinople and ravaged Justinian’s partially restored empire. It was humankind’s first bout with the bubonic plague, which was believed to have traveled to the imperial capital by rats stowing away aboard Egyptian grain ships. Dealing with the social fallout of the plague exhausted Justinian’s budget, and his attempt to retake Rome from the occupying Goths fizzled. Although it continued in name for another thousand years, the plague effectively spelled the end of the Roman Empire.

The Black Death (1347-1351)

In the mid-14th century, a mutant strain of the bacteria yersinia pestis emerged somewhere on the Asian steppe. The bubonic plague traveled with merchants on the Silk Road until it reached the shores of the Black Sea, where, once again, fleas hitching rides on merchant ship rats spread it throughout the Mediterranean. By the time it came ashore in Italy, it had mutated again. The Pneumonic Plague was transmitted via aerosols like a coronavirus, but it was much more deadly — 80 percent of infected people died within a week of the first sign of fever. By the time the final wave of the pandemic subsided, half of Europe was dead. The Black Death led to the development of the quarantine, first implemented in Dubrovnik, Croatia.

The Columbian Exchange (1492-1596)

True pandemics happen when a population is exposed to new pathogens. The most striking example of this phenomenon in human history was the European conquest of the New World. The inhabitants of North and South America were cut off from the rest of humanity for at least 10,000 years until Christopher Columbus arrived in 1492, bringing with him a variety of exotic European diseases. When he set foot on the island of Hispaniola, the Tanio people he encountered numbered about 60,000. Waves of smallpox, measles, and bubonic plague swept through the island, and 50 years later, less than 500 Tanio survived. By the time the Conquistadors set out to subdue the Aztecs, a smallpox outbreak had done their work for them. As many as 56 million Native Americans died over the course of a century, perhaps 90 percent of the pre-Columbian population. So much cropland was abandoned to forest in North and South America that atmospheric carbon dioxide fell, causing a period of climactic cooling known as the Little Ice Age.

Yellow Fever (1873-1878)

The yellow fever epidemic which spread up the Mississippi Delta in the 1870s may be small by historical standards, but it was very significant to Memphis. Two waves of the mosquito-borne disease ripped through the Bluff City, killing thousands. Refugees spread the fever as far away as Chattanooga. The city’s tax base collapsed and the city’s charter was revoked. According to historian Mary Caldwell Crosby, “the yellow fever epidemic of 1878 altered the fabric of the city forever.”

The Spanish Flu (1918-1920)

In January, 1918, the A/H1N1 influenza virus made the leap from pigs to humans on a farm in Haskell County, Kansas. It soon spread to Camp Funston, an Army base where soldiers were training for the European battlefields of World War I. By March 11, it was in Queens, New York. By April, it had reached the Western Front in France. Like the Plague of Justinian, it acquired the name Spanish Flu in May, when King Alfonso XIII of Spain became the most prominent early victim. Troop movements and the Russian Revolution hastened the spread of the deadly disease. By the end of the war, 900,000 German soldiers had come down with the flu. While most influenza strains kill the old and infirm, A/H1N1 preyed on the young, especially during the second wave which decimated Europe in the winter of 1918. The great flu marked the first time masks were used to prevent the spread of respiratory illness. By the time the final wave subsided in the spring of 1920, 500 million people had been infected, and 50 million were dead.