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kathy nguyen
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THE OUTLIERS
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96
THE ANTHRAX LETTERS
at the Manhattan Eye, Ear, ant! Throat Hospital on the Upper East
Sicle, where she cleliverec! supplies from the stockroom to the clinics
and operating rooms. Aclorecl by neighbors and co-workers, this
small unassuming woman conic! not know that at age 61 her last
desperate breaths would clefine her tragic celebrity.
"Dave, I'm not feeling well. It hurts to breathe," Kathy saic!
late Sunday morning, October 28. Dave Cruz hac! manager! the
Freeman Street apartment complex since 1981 when Kathy mover!
there. Her words were still fresh in his mine! weeks after her cleath.
From his storefront office arounc! the corner from the apartments,
Dave sharer! his thoughts ant! his laciness. A husky figure wearing a
T-shirt, he has a surprisingly soft voice. Kathy liver! alone. She was
unclemancling, he saicI, pair! her rent on time, kept her apartment
spotless. "You couicln't get any better than that."
Dave was aireacly on his way to Kathy's apartment that Sunday
morning when they encounterer! each other in the courtyard! acIja-
cent to the builcling. One of his workers hac! fount! him to say that
Kathy was urgently looking for him. When he saw her he askocI,
"Wouic! you like to go to the hospital, Kathy?" thinking of lacoby
Hospital a half mile away. "Yes, but please take me into Manhat-
tan to Lenox Hill." Dave rusher! for his minivan.
Lenox Hill Hospital is on East 77th Street, 13 blocks north of
its smaller subsidiary, "Eye ant! Ear," where Kathy worker! ant!
where elective surgery was the principal fare. Kathy's own physi-
cian was on the staff of both hospitals. After a clecacle of commut-
ing, she knew the area well. Her trip to work orclinarily began a
block from her house at the Whitiock Avenue subway station.
Twenty-five minutes on the Number 6 train to the East 68th Street
Station put her just 5 minutes by foot from work.
But that Sunday, Dave reclucec! her usual commute time by a
thircI: through some traffic lights along Bruckner BoulevarcI, over
the Thirc! Avenue Bridge to Manhattan, ant! a final uninterrupted!
stretch along the FDR Drive. As he drove, barely aware of the sun's
reflection off the East River, Dave remained focused on Kathy. He
was increclulous when she trier! to hanc! him money orclers for
2 months' rent in case of a long hospital stay, she saicI. "Put them
back in your purse, ant! clon't worry about such things now."
Kathy's laborer! breathing prompter! questions. Dic! she have
asthma? Bronchitis? he askocI. "No, no, it just hurts." He trier! to
reassure her: "Don't worry. Maybe they'll give you antibiotics." At
11 a.m. they arriver! at the emergency room, ant! he walker! her
into the examination area. Dave Cruz did not know what else to do
THE OUTETERS
97
except give her his business care! ant! a wore! of assurance before
leaving. "Kathy, please call me if you want anything."
Dr. Mayer Grosser spends much of his time in a short-sleeve
green shirt, the pajamalike top of stanciarc! hospital garb. A 13-
year veteran of Lenox Hill's emergency room, he is user! to seeing
people in distress. Kathy's case clic! not seem extraordinary. She
clescribec! her symptoms chest pain ant! shortness of breath that
hac! worsenec! cluring the previous 48 hours. He put his stethoscope
to her chest ant! back ant! heart! crackling sounds across her lungs,
an inclination of fluids. "Rales," he thought to himself. A chest X
ray also suggester! pulmonary eclema, the presence of fluids in ant!
arounc! the lungs, all of which he thought pointer! to the probabil-
ity of congestive heart failure.
Kathy worrier! that her illness ant! her absence from work
would cause some inconvenience to her employer. "How can we
get in touch with my boss?" she wonclerecI. "I have to tell him I'm
not going to work tomorrow." "Don't worry," Dr. Grosser assurer!
her. "We'll take care of that." Meanwhile, he ponclerec! over her
medical history. The only hint of abnormality was her elevates!
blooc! pressure, but that was uncler control with daily pills. After a
few hours on nitrates ant! a diuretic for presumer! heart failure,
there was no improvement. An echocarcliogram later confirmed!
that she hac! no heart abnormalities.
About 5 p.m. Grosser looker! again at her chest X ray. "I saw
the wiclenec! mecliastinum ant! it hit me. I thought, 'This could be
anthrax."' He askocl her if she workocl near the mailroom. "Yes,"
she saic! ant! explainer! that the mailroom was attacher! to the cen-
tral supply room. "I never mentioner! the wore! 'anthrax,' ant! she
clicin't either," he saicI. "But she was a smart woman ant! she be-
came visibly concerned! after that." By then he hac! her taking large
closes of Levaquin, an antibiotic in the ciprofloxacin family. At 7
p.m. Kathy Nguyen was mover! to intensive care.
By the time Dr. Bushra Mina saw her at 9 p.m., Kathy's breath-
ing was more clifficult. She was lucic! but toic! him she was very
tirecl. Mina, a pulmonary and critical care specialist, was aware of
Grosser's presumptive cliagnosis. Slightly built and soft spoken, Dr.
Mina recallec! how worrier! he was about Kathy's unusually rapic!
deterioration. "She seemec! to be weakening by the minute," he
saicl, and he ordered an intubation tube to help her breathe. In-
sertec! through her nose into her trachea, the tube also preventer!
her from speaking. Arouncl midnight she seemed stable, and Mina
went home for a few hours of sleep.
98
THE ANTHRAX LETTERS
When Dr. Mina returnee! at 6 a.m., he hac! Kathy seciatec! while
he performer! a bronchoscopy, which enabler! him to peer into the
small passageways that branches! throughout her lungs. His
viewfinder became immerses! in bloocly, infected! fluids. During the
remainder of the clay, despite placement of tubes to drain the fluids
from her chest, her condition worsened. She lapser! into uncon-
sciousness, ant! her organs began to fail.
Meanwhile, on that same clay, Monday, the results of testing at
the large Morgan mad! distribution center at 9th Avenue ant! 29th
Street in Manhattan were announced. Five of the sorting machines
hac! small amounts of anthrax, though no postal workers hac! be-
come infected. The letters that hac! causer! the seven cases of an-
thrax in the New York City meclia offices apparently hac! been
router! through those machines. The two recoverer! letters, to NBC
ant! the New York Post, hac! first been processes! on September 18
at the Hamilton center in New lersey ant! then forwarclec! to Mor-
gan.
. . . .
Now, the news about Kathy's inhalation infection unnerves! ev-
eryone. Could she have been exposer! to anthrax from cross-con-
taminatec! mad! that, 40 clays earlier, hac! gone through Morgan?
Was a new attack uncler way? The New York Metro Area Postal
Union urger! that the Morgan facility be shut clown. But the postal
authorities closet! off only the contaminates! sections on the seconc!
ant! thirc! floors. Davic! Solomon, a postal service spokesman, saic!
the builcling wouicl remain open because "health professionals
[have not said there is a health cianger for our employees." Still,
workers were worried. The absentee rate at the facility climber! to
30 percent.
As word circulatecl in both hospitals about Kathy's anthrax,
anxiety among hospital personnel also rose. At the request of the
city health department, patients from Manhattan Eye ant! Ear were
mover! out ant! the hospital was closed. A week later, after no an-
thrax hac! been fount! there, the hospital reopened. During the clos-
ing, 250 surgeries were canceled, ant! by the enc! of the week the
hospital had lost about $1 million in revenue. Dr. Thomas Argyros,
the meclical director at Lenox Hill, recallec! the atmosphere at the
time:
The dynamics were terrifying because of the possibility that she got
the anthrax at the hospital. Anyone who had been in Eye and Ear
since around October 15 had to go for prophylaxis. About 2,000
people were screened here fat Lenox Hill] and at Pnearby] New York
Hospital, and they went on antibiotics.
THE OUTETERS
99
One of the people screener! at Lenox Hill, Daisy Cruz, hac!
been to the Eye ant! Ear Hospital on October 18 for a hearing test.
At her screening for anthrax, she saic! that she was "crazy" with
fear: "I see anthrax in the toothpaste. I see it in the orange juice. I
see it in the sugar. They're going to kill me with a heart attack
before they kill me with anthrax."
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..... ~Y ~.~ -.~,
The New York City Health Department first heart! about Kathy
Nguyen on Sunday night, October 28. Dr. Michael Tapper, head of
infectious diseases at Lenox Hill, hac! caller! Marcelle Layton, the
city's assistant health commissioner. "Marc), I think we have a
problem. I think we may have a case of inhalational anthrax." The
next clay members of her staff joiner! with law enforcement offi-
cials to speak with the staff at the hospital. Among those who went
to the hospital, Timothy Holtz ant! foe! Ackelsberg became the
leac! epiclemiological investigators for the case. Dr. Holtz hac! ar-
rivec! in New York only 2 months earlier as a temporary "preven-
tive medicine fellow" from the Centers for Disease Control ant!
Prevention. Dr. Ackelsberg hac! just joiner! the department in 2000
as its coordinator of bioterrorism preparedness.
Holtz ant! Ackelsberg are contrasting figures in appearance as
well as background. Holtz's closely cropped, fire-rec! hair, mus-
tache, ant! bears! seem out of phase with his laicI-back demeanor.
His baritone voice is flat ant! even, revealing few signs of emotion.
In contrast, Ackelsberg, in blue jeans ant! rumples! green jacket,
necktie askew, speaks in sonorous tones, a hint of the actor he once
aspirer! to be.
Their paths to medicine could harcIly have been more clissimi-
lar. Holtz's was all Iowa. He grew up there ant! went to college ant!
meclical school at the University of Iowa. For Ackelsberg, at age
50 12 years oicler than Holtz meclical training came much later.
"I hac! been a typical 60s kic! who hac! gone to a number of schools
in a number of places," he saicI. Before completing Tufts Meclical
School in 1993, he hac! variously been an actor, a carpenter, ant! for
10 years in San Francisco a cab driver. Both men went on to train in
public health, ant! both server! for 2 years with the CDC's Epidemic
Intelligence Service before coming to New York City. Now, the two
would work in tanclem, meclical sleuths in search of the source of
Kathy Nguyen's anthrax.
100
THE ANTHRAX LETTERS
On Monday morning, when Holtz first heart! about the suspi-
cion that there was a new inhalation anthrax case, he thought,
"Nah, that can't be possible." Like others in the department, he
thought New York's seven cutaneous cases were all they wouic! be
seeing. Later that clay, the department learner! that the new case
hac! been confirmed. Holtz recallec! his feelings:
Marci Layton asked me to get involved and be sort of the head of the
epidemiology investigation at the patient's workplace, and I thought,
"Okay, here we go again." It's like it's not over. It was one thing to
have cutaneous cases, but when you have an inhalation case, well we
were all extremely worried about what was going to happen that
week, that this was a harbinger of worse things to come.
Uncler Layton's overall coordination, Ackelsberg ant! Holtz be-
came "sort of the two team leaclers," in Holtz's words. After their
first visit together to Lenox Hill they cliviclec! responsibilities.
Ackelsberg: "I was focusing more on interviewing friends, seeing
her apartment, trying to learn about her and her activities." Holtz:
"I was the one who mainly spoke to her co-workers, people at the
hospital she workocl at."
Holtz recallec! that when investigators met to interview work-
ers at the Eye and Ear Hospital, agents from the Fecleral Bureau of
Investigation were reluctant to enter the buildings They were con-
cernec! that it was contaminated, though the health department staff
felt the risk was minimal. "In the encl, there were two FBI agents
who agreed to go inside with us. The rest of them stayocl across the
street in a hotel ant! clic! some interviews over there," saic! Holtz.
One of the people that Ackelsberg interviewocl was Anna
Rodriguez. Weeks after Kathy's cleath, Anna was still stunned. She
hac! known Kathy since the early 1980s when Kathy mover! to the
newly renovated Bronx apartment buildings "A classy lacly," Anna
saic! about Kathy, "always neatly ciressecI." Ant! her apartment? "It
was so clean you could eat off the floor." Kathy's monthly rent,
which she pair! by postal money orcler, was $675. The builcling was
a Section 8 apartment house, which meant that her rent was 30
percent of her gross income. ("Section 8" refers to a fecleral pro-
gram that provides housing subsidies for low-income families.)
Kathy's annual income was about $27,000.
"I user! to help her with filling out applications ant! money
orclers," Anna said Kathy was scrupulous about meeting her obli-
gations, and her rent was always paid on time. Her heavily ac-
centec! English could be clifficult to unclerstanc! until you got user!
THE OUTETERS
101
to it, Anna saicI. But she conveyor! a kinciness that macle people fee!
comfortable.
Anna ant! Kathy would come across each other on the elevator
or in the triangular courtyard! outside the builcling's entrance. "Ev-
ery time I saw her she would ask how I was, how my family was."
She ant! Kathy hac! been to each other's apartments over the years.
"Kathy once macle wonton soup ant! fries! rice for me," saic! Anna.
Ant! Kathy often gave little gifts to the neighbors fruit, a hanc~ker-
chief. But even after all those years Anna wasn't sure how well she
really knew Kathy. "Everyone likes! Kathy," Anna saicI, "but you
never saw her with anyone else. She was always alone." Kathy
seemec! to be entirely on her own, "no relatives that I knew, though
I heart! she hac! a cousin in Seattle."
Anna Rocigriguez lives in 5R, two floors above Kathy's apart-
ment. Her moclest-sizecl living room is lively with color, family pic-
tures, ant! cabinet shelves liner! with decorative clishes ant! vases.
"The room layout in Kathy's apartment is the same as mine."
Three weeks after Kathy's cleath, across the corridor from the
thircI-floor elevator entrance, the heavy black floor to Kathy's apart-
ment remainec! boltecI. Her picture ant! a brief article about her,
clipped from a Spanish-language newspaper, were taped to the floor.
A separate notice saicI: "These Premises Have Been Sealer! by the
New York City Police Department." Beneath the notice a peephole
allowed! for a partial view of the interior. The livingroom rug was
gone, ant! the floor's wooclen slats were bare. Furniture hac! been
mover! from the center area. Against the wall on the left sicle, a 3-
foot-tall shelf supporter! a plant whose leaves were witherer! be-
yonc! recovery. Farther along the shelf were a coffee mug, a small
basket, ant! a few books. Towarc! the far wall a low wooclen stool
was visible.
Investigators who visitec! Kathy's apartment after she was cliag-
nosec! with anthrax were impresser! by how much was in it. foe!
Ackelsberg was part of the team looking for clues. Months later he
recallecl his impressions: "There was a lot there. She saved mad! and
oic! receipts." Trinkets were plentiful, also lots of clothes ant! shoes.
"I saw two dozen shoeboxes," he saicl. The CDC's Stephen Ostroff
described Kathy as a "conscientious saver." Ostroff saw neat piles
of " junk mail, some from 10 years ago, that were asking for clona-
tions." Since she kept the apartment extremely clean, Ostroff won-
clerecl if she might have wiped out any anthrax that might have
been there.
The fact that Kathy's anthrax at first seemec! unconnected! to
102
THE ANTHRAX LETTERS
the mad! was, to some, strangely encouraging. By tracing where she
hac! been in recent weeks shops, parks, subway lines investiga-
tors thought the trail might leac! to the perpetrator. They believer!
that "along those routes she might have intersected! with the person
or people behinc! the anthrax attacks," according to a New York
Times report. No less intriguing was her place of work. The base-
ment stockroom at the hospital was next to the mailroom. But a
few weeks after her cleath, none of the huncirecis of tests for an-
thrax there or elsewhere shower! any inclination of anthrax. Nor
were the interviews with friends ant! co-workers any more helpful.
Law enforcement officials hac! even tracker! clown a former hus-
bancI. Kathy hac! been marries! briefly some years earlier, though
she hac! not seen her ex-husbanc! or other relatives for clecacles.
Eager for leacis, FBI agents manager! to locate him. He toic! them
that Kathy user! to like to smell things. "We certainly were intrigues!
by that," said Ackelsberg. The team considered flowers and any-
thing else she might have smeller! as a possible source of the an-
thrax. "But, again, nothing came up."
Kathy's clecacle at the Eye ant! Ear Hospital hac! left an impres-
sion similar to the one helc! by her neighbor, Anna Rodriguez.
Esperanza Vassello, the hospital's heat! clietician, hac! been at the
hospital since emigrating from the Philippines 30 years earlier. A
few weeks after Kathy's cleath, "Espie" sat in her office, next to the
large kitchen she supervises. She hac! a strong face ant! spoke with
conviction. "See that?" she asker! me, pointing to a brown-framec!
desk clock on a shelf to her right. "Kathy gave it to me for my
birthday." She recallec! the conversation she hac! with Kathy less
than 2 months earlier.
"Espie, here is your birthday present," Kathy saicl.
"But it's only October 8 and my birthday is November 7."
Kathy smilecI. "I want you to use it longer. Happy birthday."
Kathy gave presents, ant! not just for birthdays, to everyone at
work earrings, cologne, foocl. Espie noted that Kathy "hail a
problem with language and understanding forms." So, as she did
with Anna Rodriguez, Kathy would ask Espie for help in filling out
money order requests and other forms. Espie felt that they had
become closer during the previous year or so. But she was surprised
to learn from a newspaper article after Kathy's cleath that she hac! a
cousin in Seattle. "She had toicl me that all her family members
were killecl in the Vietnam War and that she had no relatives here."
Ackelsberg summarizes the view of the investigative teams:
THE OUTLIERS
The impression we had was that she was a woman who worked and
lived according to a set schedule, that she missed very few days of
work. She was very friendly. She was considered extremely generous.
At the same time, the people we were directed to as being really close
friends well, if they were as close as anyone got to her, then she
lived a fairly isolated existence.
Yew ..~ ~~.:.Y~.
Y - ; x , - ~
.. BY.< I' - Am.. Y. ~]
yin ray, my.,
A. :: As.
103
Was Kathy Nguyen's end foreordained when she swung open
the little brass door on her mailbox and retrieved a letter dotted
with particles of death? Or did she inhale a lethal dose from some
other source?
By the time of her death, 4 weeks had elapsed since Bob Stevens
had become the first fatality of the anthrax terrorism. During those
weeks, eight more people became infected with inhalation anthrax
and 11 with the less dangerous cutaneous form. Thousands of
people were hoarding Cipro and other antibiotics deemed effective
against anthrax. Gas masks were selling briskly, even chemical pro-
tective suits. People were opening mad! in their garages and scrub-
bing their mailboxes with bleach. Contaminated postal facilities,
business offices, and the Hart Building, which housed the offices of
half the U.S. Senate, were closed. Postal authorities reported a sharp
decline in the volume of mail.
CDC protocols state that health care workers caring for an-
thrax patients are not at risk and that they need not take antibiot-
ics. Nevertheless, after Kathy Nguyen was diagnosed with anthrax,
both Dr. Mayer Grosser and Dr. Bushra Mina, who had seen her at
the hospital, started on Cipro. After a few days, Grosser was in-
clined to stop, but his wife would not let him. "She insisted on
watching me take the Cipro, one pill in the morning and one at
night."
On Wednesday, October 31, Kathy Nguyen went into cardiac
arrest and at 1 p.m. she died. Blood cultures and autopsy findings
confirmed that anthrax had colonized all her organs. On the day of
her death, the New York Times ran stories about Kathy Nguyen
under a three-column headline: "Hospital Worker's Illness Suggests
Widening Threat; Security Tightens Over U.S."
A week after Kathy's death, no new cases had been reported.
"I'm hopeful, like the rest of America, that the anthrax has stopped
permanently," said Tom Ridge, President Bush's director of home-
104
THE ANTHRAX LETTERS
lane! security. But by micI-November, hopes that the outbreak hac!
enclec! were abruptly set back.
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Ten miles south of Waterbury, Connecticut, Route 67 leacis to a
small wooclen bridge ant! a sign that says "Welcome to Oxford."
Oxforc! was establisher! in 1789, the year George Washington was
inaugurates! president of the Uniter! States. Two centuries later the
number of inhabitants hac! grown from 1,400 to 9,800, a compara-
tively moclest increase. During the same perioc! in New York City,
then as now the nation's largest city, the population rose from
33,000 to 8 million. Locater! 75 miles north of New York, Oxforc!
is a rustic community where agriculture ant! farming continue to
flourish.
Along Great Hill RoacI, just past Immanue! Lutheran Church,
a roar! to the right opens to a patch of single-family homes. One
such home, on Ecigewooc! Drive, stancis behinc! neatly trimmer!
hedges ant! a tall flagpole. A black mailbox bearing the number 16
is percher! on a white post near the curb. Towarc! the rear of the
house, the backyarc! slopes into a valley of maple ant! oak, naked! in
the January coicl. The house is empty. Six weeks earlier, on Novem-
ber 21, 2001, its owner, Ottilie Luncigren, succumbec! to anthrax.
At 94 she was the oiclest of the 11 inhalation anthrax cases. Al-
though the source of her infection, like that of Kathy Nguyen's,
remains uncertain, Ottilie's seems even more puzzling. Her activi-
ties were limitecI, easily traced, ant! seemingly unrelated! to any
source of anthrax.
Whereas Kathy Nguyen hac! been part of the hubbub of New
York City the crowds, the subway, the shops in Chinatown-
Ottilie largely remained! at home in a rural, quiet community. "We
were left with major gaps in the time line of Kathy's activities," foe!
Ackelsberg saicI. This was not the case with Ottilie. She was chilcI-
less ant! since her husbancl's cleath 24 years earlier, she liver! alone.
Neighbors wouicl stop by, as clicl her niece, Shirley Davis, who livecl
30 minutes away in Waterbury, Connecticut. Ottilie hac! given up
driving a year earlier and had become dependent on them to help
her with shopping. They wouicl drive her to the church clown the
roacl, to the beauty parlor, and to lunch at Fritz's Snack Bar on
Highway 67 where she would orcler minestrone soup ant! lobster
rolls.
THE OUTLIERS
105
Although siowoc! by age, Ottilie remained! remarkably alert. At
one time a manager of her husbancl's legal office, she was still a
quick thinker ant! a reacler of travel ant! mystery stories. Robin
Shaw, a half century younger, had for the past 10 years been Ottilie's
hair ciresser at the Nu Look Hair Salon. "She was a sweet woman,
intelligent, ant! very frank," saic! Robin, who looker! forward! to
seeing her every Saturday morning at 11. Ottilie could effortlessly
shift from reciting poetry to gentle chicling. A fastidious, conserva-
tive ciresser herself, she may have seen in Robin's fluffy dark hair
and colorful clothes some opportunity for improvement: "Robin,
your outfit. Couicin't you choose a better color match?" "Now
clon't hoic! back, Ottilie," Robin repliecI. Ant! both broke into
laughter.
Weeks after Ottilie cliecI, Shirley Davis talker! with me about
her aunt over lunch. Dressecl in a black succle jacket and maroon
sweater, a thin goic! necklace below her turtleneck collar, Shiricy's
meticulous appearance is reminiscent of her aunt's. At 72, Shirley,
who hac! rearer! her own children, was young enough to have been
Ottilie's daughter. "We became especially close in recent years,"
Shirley says. Born ant! raiser! in Waterbury, like Ottilie, Shirley still
lives there. She visitec! Ottilie several times a week to check on her
ant! help arounc! the house. Only after her cleath clic! a ritual of
Ottilie's take on significance:
Someone would bring in the mail from the mailbox along the curb.
And I watched many times as Ottilie sorted it. Sometimes I sat at the
card table with her. She would open each letter with a letter opener.
Every letter that she did not save, she would tear in half, into two
pieces, and discard it into a wastebasket underneath the card table.
Sometimes I would rip them for her. She filed and organized all the
mail that she kept. Then she would empty the wastebasket into a
garbage bin outside the back door.
"I nearly fainter! when the doctors toic! me they suspected!
anthrax," Shirley saicI, her eyes beginning to water. How could her
aunt ever have been exposed? Her life was clistant from mailing
facilities ant! population centers. Her infrequent outings never took
her more than a few miles from home. Shirley recallec! that Ottilie
hac! been feeling out of sorts for a few clays mile! cough, weak-
ness and that she rejected Shiricy's pleas to call her cloctor. But
with Shirley in her home on Friday morning, November 16, she
relentecl. Ottilie's doctor suggested that she stop by the emergency
room at Griffin Hospital in nearby Derby.
106
THE ANTHRAX LETTERS
William Powanda, the burly gray-haired vice president at
Griffin, recounted Ottilie's relatively benign symptoms: low-grade
fever, slight dehydration. "Classically, she would not have been ad-
mitted, but because of her age we decided to let her stay." The
remainder of that day and into the next Lundgren barely seemed
ill. She joked with visitors and medical attendants; her initial tests
suggested a possible urinary tract infection. On Saturday morning
Dr. Lydia Barakat, one of the hospital's infectious disease special-
ists, received a call from the intern on duty. Lundgren's overnight
blood cultures had grown bacteria that were rodlike and tested
Gram positive. Barakat had not yet seen Lundgren, but she thought
"elderly patient; probably clostridium." She ordered Ottilie on an-
tibiotics, vancomycin and ceftazidime, as she set off to the hospital
to see the patient. Later she added oral Cipro and intravenous ampi-
cillin to the treatment.
Clostridium bacteria, at least the type most often found in hu-
mans, are rarely life threatening. When Barakat arrived at the hos-
pital around 10 a.m., she went to the laboratory, checked
Lundgren's reports, and looked at her chest X ray, which appeared
normal. She peered through the microscope and saw the cultured
bacteria all consistent with clostridium. Barakat, an attractive
young woman who attended medical school in her native Lebanon,
had completed her residency at Griffin only 2 years earlier. That
Saturday morning, the case hardly seemed extraordinary, certainly
nothing to warrant interrupting the weekend of the hospital's in-
fectious disease chief, Howard Quentzel. Still, in the back of
Barakat's mind lay another truth: Gram- positive rods are also con-
sistent with anthrax.
"I was thinking clostridium, but I had been hearing a lot about
anthrax," Dr. Barakat later said. She went to Ottilie's room. While
examining her, Barakat asked, "Did you receive any mail with pow-
der in it?" Ottilie answered, "No." She did not seem very ill and
had no respiratory problems, and Barakat was reluctant to say "an-
thrax" to anyone else. "I did not want to make a fool of myself,"
she told me. On Sunday Lundgren seemed more short of breath. A
new chest X ray, unlike the earlier one, suggested that fluid might
be present in one lung. By Monday morning, after more tests, it
became clear that Ottilie's infection was not from clostridium but
from a bacillus.
The new tests showed that the bacteria were nonmotile and
nonhemolytic that is, they did not move spontaneously and did
not destroy red blood cells. This ruled out Bacillus cereals, a treat-
THE OUTETERS
107
able and rather common infective agent. Meanwhile, Barakat hac!
briefed Dr. Quentze! about the patient, and he was eager to see her
when he arriver! at the hospital on Monday. Another chest X ray
hac! just been taken, the third since Luncigren entered the hospital.
This one showed fluid throughout both lungs, though no wiclenec!
. .
mec ~ast~num.
Howard Quentzel, at Griffin for 13 years, hac! gracluatec! from
New York Meclical College and completed his residency in infec-
tious diseases at Lenox Hill Hospital. There he hac! workoc! uncler
Dr. Michael Tapper, the man who, weeks earlier, hac! overseen the
care of Kathy Nguyen. Quentzel's slight builcI, high forehead, and
large glasses present a scholarly appearance. Earlier he hac! re-
viewoc! his textbook to make sure which bacilli are nonmotile and
nonhemolytic. The prime cancliciate: Bacillus anthracis. He and
Barakat met to review Luncigren's chart. He turned to her and saicI:
"This is anthrax."
"I'm relievecI," Barakat thought to herself. Barakat felt as
though a burclen hac! been lifted from her. Now someone else also
accepted the seemingly preposterous notion that Ottilie Luncigren,
this stay-at-home nonagenarian, could have anthrax. But what else
could it be? Quentze! went to see Ottilie, who was still quite coher-
ent. "Dic! you travel to New York?" he askocI.
"No, I haven't," Ottilie saicI.
As clic! Barakat earlier, he askocI, "Dic! you see any powder in
the mail?"
"No."
Barakat and Quentze! unclerstooc! the explosive implications of
their diagnosis. The country was aireacly in turmoil over anthrax.
The Luncigren case would acic! a new dimension to the fright. If
someone so unlikely could become a victim, everyone might be at
risk. If Ottilie's illness were connected to a letter contaminated by
an aireacly cross-contaminatec! letter, the implications were pro-
founc! incleecI. Her letter then could have been part of an infective
chain reaction. Third- or fourth-generation cross-contamination
could have devastating implications everywhere. Even the limited
comfort in knowing that anthrax clic! not spread from person to
person could be unclerminecI. Routine mad! might become the an-
thrax equivalent of the contagious smallpox cough or the touch of
a plague-infectec! hancI.
An ominous comment in 1981 by Rex Watson, then head of
Britain's chemical and biological defense establishment, seemec! al-
most an understatement. If Berlin hac! been bombarclec! with an-
108
THE ANTHRAX LETTERS
thrax in 1945, he saicI, the city would! still be uninhabitable. But he
was speaking of massive quantities of spores. Now the Uniter! States
seemec! to be hostage to a few grams. The randomness, the far-
flung locations, ant! the uncertainty of who might be next over-
shaclowoc! the limiter! number of victims thus far.
Barakat ant! Quentze! knew their lives were about to be clis-
ruptecI, as were those of others in the hospital, not to mention
Ottilie Lunclgren's neighbors, friencls, ancl family. They cleciclecl on
a division of responsibility. Barakat wouic! focus on taking care of
her patient ant! try to clisregarc! the inevitable distractions. Quentze!
wouic! notify the appropriate hospital authorities, state health offi-
cials, ant! the fecleral government through the CDC. "I was ex-
citecI," Quentze! acknowlecigec! in reflecting on that moment. "I
knew what this meant."
Quentzel's calls to state ant! fecleral officials were initially re-
ceivec! with skepticism. "When I spoke to the EIS Epidemic Intelli-
gence Service] officer, he sounclec! surpriser! ant! just saicI, 'OK, we'll
pick up the culture."' The EIS was establisher! in 1951, cluring the
Korean War, when the Uniter! States worrier! that the Soviet Union
might attack with biological weapons. An arm of the CDC, it was
to serve as an early warning system against germ warfare. Through
the years its investigators cleterminec! that several disease outbreaks
were natural ant! not man-macle. Now, after 50 years the EIS was
clearing with something different. The country was facing a true
. . .
~loterrorlsm siege.
As Quentze! began clearing with the outside authorities, Barakat
thought, "Thank Got! he'll be taking care of the phone. For me I
was focused on wanting to help the patient."
On Monclay, Ottilie Lunclgren was intubatecl, ancl that after-
noon her chest was cirainecI. "I was optimistic even until Tuesday,"
Barakat saicI, "but then she clevelopec! multiorgan failure." About
the same time, on Tuesday, November 20, Quentze! heart! from the
EIS that Ottilie's blooc! samples hac! been confirmed! for anthrax
both by the state ant! CDC laboratories. By then it was clear there
wouic! be no recovery. Ottilie Luncigren flier! the next clay.
By the enc! of the following week, investigators hac! taken 83
swabs ancl samples at Ottilie's home ancl scores more at places she
hac! recently visited, inclucling the Nu Look Hair Salon, the town
library, Fritz's Snack Bar, ancl Immanue! Lutheran Church a mile
from her house. Early testing also incluclecl 29 samples from the
post office in Seymour that servicer! her home ant! 117 samples at
THE OUTETERS
109
the large postal distribution center in WallingforcI. All tester! nega-
tive for anthrax.
Investigators were becoming desperate for clues. The lane!
arounc! Luncigren's house was scourer! for anthrax spores. But, as
with her mail, furniture, clothes, ant! other wordily goods, there
was no sign of the bacterium. As with Kathy Nguyen, investigators
wonclerec! if she hac! somehow come into contact with a perpetra-
tor posing as a friend. "Dic! she have any boyfriends?" an FBI agent
asker! Robin Shaw, Ottilie's hairdresser ant! friend. "No," saic!
Robin, who was both startler! ant! amuser! by the question. At age
94? Robin was astonishes! by how far the authorities were trying to
reach.
In later weeks, a connection to the mad! seemec! more probable
it not conclusive. Aciclitional testing shower! the presence of an-
thrax spores on four of the 13 high-speec! sorters at the Wallingforc!
center ant! trace amounts at the post office in Seymour. About a
thousanc! postal employees in the area hac! been starter! on preven-
tive antibiotic treatment. A computer printout shower! that a letter
that went to the Wallingforc! facility hac! come from the Hamilton
center in New Jersey. The letter hac! been sorter! 15 seconds after
the Leahy anthrax letter ant! on the same machine. Aciciressec! to
lack Farkas at 88 Great Hill Roar! in Seymour, the letter was fount!
at his house ant! prover! to have a trace of anthrax. No one in the
Farkas home, which was 4 miles from Ottilie Luncigren's, hac! be-
come infected. But the presence of the letter heightener! the possi-
bility that cross-contaminatec! mad! might have reacher! Ottilie's
home.
In March 2002, lames HacIler, the Connecticut state epiclemi-
ologist, revealer! that the contamination at the Wallingforc! center
hac! been greater than previously suggested. Although three of the
machines hac! small numbers of spores, the fourth was "heavily
contaminates! [with] approximately 3 million spores, roughly
translates! into 600 infectious closes." HacIler believes the evidence
is "strongly suggestive" that Ottilie was exposer! through the mail.
He says that 29 letters were recoverer! from her home. Six were
first class letters that hac! been "cleanly opener! along the top bor-
cler" ant! hac! been processes! only in Connecticut. But of 23 items
of bulk mail, "all were torn in half ant! hac! been fount! in her
trash." All 29 pieces culturecl negative for anthrax. Still, he be-
lievec! that Ottilie was exposer! to cross-contaminatec! bulk mail.
How couicl this have occurrecl? Hacller conjecturecl:
110
THE ANTHRAX LETTERS
Well, it's possible that a load of cross-contaminated bulk mail from
New Jersey was initially sorted on the heavily contaminated machine
in the Connecticut distribution facility, resulting in widespread con-
tamination of that machine.... One of these pieces of mail, or possi-
bly another that was cross-contaminated on this machine, then con-
taminated the sorting machine for her postal route before reaching
her home. She was exposed to airborne spores released when she tore
this piece of cross-contaminated mail in half something, again, she
only did for bulk mail, not for first class mail.
Fear of anthrax hac! become compounclec! by the uncertainty
of how Kathy Nguyen ant! Ottilie Luncigren hac! become infected.
Could the source of their exposures have been so minute as to go
uncletectec! despite all the sweeps for evidence? Quite possibly. Ac-
corcling to Donalc! Mayo, who worker! with the Connecticut Public
Health Laboratories cluring the anthrax outbreak, "You know, un-
less you swab every square inch, of course you may miss some
spores. You cannot be sure that you've gotten every last one."
The actual number of spores necessary to cause infection re-
mains clisputecl. Before 2001, animal experiments and sparse infor-
mation from human experience suggester! that a person who in-
halec! 8,000 to 10,000 spores hac! a 50 percent chance of becoming
lethally infected. After the outbreak, however, the issue seemec!
more murky. The "preferrer! interpretation," according to lames
HacIler, is that Kathy Nguyen ant! Ottilie Luncigren receiver! expo-
sures from "small numbers of spores."
Jeffrey Koplan, then the CDC director, was skeptical. "It wouic!
take a lot more than a few spores to cause inhalation anthrax," he
saicI. But Matthew Meselson, a Harvarc! microbiologist, clisagreecI:
"There is no justification for assuming there is any threshoicl at
all." Although the chance is small, "a single organism has a chance
of initiating infection."
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In 2001 the Defense Research Establishment Suffield (DRES),
a Canadian government agency, produced a study that was remark-
able in its timing. Titlec! Risk Assessment of Anthrax Letters, the
stucly hac! been undertaken because "no experimental stuclies on
which to base a realistic assessment of the threat posed by . . .
'anthrax letters' could be found." The report of the stucly was dater!
September 2001, the very month the first anthrax letters were
THE OUTLIERS
111
mailer! in the Uniter! States. The impetus of the stucly was a letter
receiver! by a government office earlier in the year claiming to con-
tain anthrax. That threat prover! to be a hoax. But it inspirer! DRES
to conduct a series of experiments.
Each trial involves! placing a letter ant! a quantity of bacteria,
ranging from 0.1 to 1 gram, in an envelope. After sealing the enve-
lope with the flap's adhesive, it was shaken ant! brought into a 10 x
18 foot chamber. There a tester in mask ant! protective outerwear
"playful the role of mad! clerk." He tore open the envelope and
remover! the letter. The relatively harmless bacteria (a simulant of
anthrax bugs caller! Bacillus globigii) floater! out. Culture plates,
which could grow colonies from bacteria that settler! on them, hac!
been placer! arounc! the room to see how far the germs spread. The
results were stunning:
Before starting the experiments, it was assumed the opening of an
envelope constituted a very "passive" form of dissemination that
would produce minimum aerosolization of the BG spores.... This
assumption proved incorrect....The high concentration and rapid-
ity with which the aerosol spread to the other end of the chamber
twere] also unexpected. The very heavy contamination on the back
and front of clothing worn by the subject Ltester] was also unex-
pected.
Within 45 seconds of the time of release, bacteria hac! spreac!
everywhere, inclucling onto the breathing filter of the tester's mask.
The report suggests that the stucly's "dramatic results" clemanclec!
better preparation for an attack with germs sent by mail. "It is only
a matter of time until a real 'anthrax letter' arrives in some mail
room," the report concluclecl.
As eminently correct as that observation prover! to be, another
of its admonitions fell short. Failure to seal an envelope's corners,
according to the report, "could also pose a threat to inclivicluals in
the mail hancIling system." True. But the implication is that bacte-
ria wouic! not escape from a well-sealec! envelope. A month later,
cluring the anthrax letter crisis, investigators realizer! that the 1- to
3-micron spore particles were leaking not through leaky flaps but
through 20-micron pores in the paper envelope.
In its conclucling paragraph the DRES report notes! that similar
experiments hac! recently been concluctec! by another agency in
Canada, the Ottawa-Carieton First Responder Group. In that stucly,
titlecl Investigation on the Dispersal Patterns of Contaminants in
Letters, the Ottawa-Carieton group placed fingerprint powder in
112
THE ANTHRAX LETTERS
envelopes. The results were similar. Even when the envelopes were
not physically openecl, powder leakocl out and caused "contamina-
tion in the immediate area."
The risk of anthrax in the mad! was also assesses! in William
Patrick's 1999 stucly for the Scientific Applications International
Corporation. The report is not publicly available, but Patrick
sharer! information about it with William BroacI, a New York Times
reporter. Patrick inclicatec! that a puff of aerosol bacteria emerging
from an envelope could be lethal. But there apparently was no incli-
cation in his report, or in the two Canadian stuclies, that cross-
contamination could magnify the potential for cleath.
lust how long would a contaminates! mailbox retain spores?
Kathy Nguyen's and Ottilie Lunclgren's mailboxes tested negative
for anthrax. But the tests were undertaken clays after the women's
diagnoses ant! probably weeks after an infectec! mad! item would
have arriver! in their boxes. If a slightly contaminates! letter left
spores in a mailbox, how long might it take for subsequent cleliver-
ies ant! retrievals to clear the spores from the box?
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Late in 2002, I concluctec! a stucly to help answer that question.
Publisher! in the fo?~rnal of Public Health Management and Prac-
tice (September 2003), it is titles! "Persistence of a Mock Bio-agent
in Cross-Contaminatec! Mail ant! Mailboxes." The stucly incluclec!
three trials, each concluctec! in the same manner. A trial would be-
gin with the placement of 1 gram of a mock biological agent ant! a
sheet of paper in a prestampec! postal envelope, much like those
user! in the real anthrax mailings. The agent, caller! " Glo Germ," is
a fine white powcler composer! of 5-micron particles that approxi-
mate the size of anthrax spores. The particles are fluorescent ant!
strikingly visible uncler an ultraviolet light. Glo Germ is user! to
check hygienic and infection control practices in hospitals and
among foot! hancIlers. It has also reportecIly been user! by the U.S.
Army as a tracer in mock germ warfare tests.
After sealing the envelope flap ant! its corners with tape (as was
clone with the real anthrax letters), the envelope is placer! in two
Ziploc plastic bags, one insicle the other. The bags are shaken ant!
squeezed, to simulate the turbulence causer! by a mad! sorting ma-
chine. The letter is then remover! ant! replacer! with six uncontami-
natecl letters. Again, the bags are shaken. The six letters are re-
THE OUTETERS
113
mover! from the bags ant! placer! in a rural mailbox much like the
one user! by Ottilie Luncigren. After 3 minutes, the letters are re-
movec! from the mailbox. Fluorescent particles on the letters ant!
on the floor of the mailbox are counted.
The exercise is repeated: Nine more deposits ant! retrievals in
the same mailbox are performed, each with a new batch of six
uncontaminated! letters. After each "mailing," the letters ant! the
floor of the mailbox are examiner! for the presence of particles.
The first six letters in each trial are the only ones that have hac!
direct contact with an originally contaminates! letter. Not surpris-
ingly, the total number of particles in each of these initial batches
was high exceeding 50 particles. In all three trials, the number of
particles that is, the level of contamination clecreasec! in the
course of the 10 mailings.
Particle counts on the floor of a mailbox after the first mailing
varier! in each trial. In the first trial the figure exceeclec! 50, in the
seconc! it was 32, ant! in the thirc! it was 24. The enumeration of
particles was in part subjective because some of the fluorescent
spots appearec! as smudges rather than discreet points. (A smudge
may have represented! several particles or otherwise been an arti-
fact, but each was recorclec! as one particle.) Still, the trenc! was
clear. After the fourth or fifth mailing, traces of fluorescent par-
ticles were largely absent from the letters. While traces in the mail-
boxes themselves persisted somewhat longer, their numbers also
cleclinec! with successive mailings. IncleecI, in the first trial, after the
tenth mailing, no particles were visible in the mailbox. In the other
two trials, after 10 mailings, two particles remained in each.
This exercise demonstrates that successive placements ant! re-
movals of letters in a mailbox may cause a clecline in the number of
resiclual bioagent particles. It supports the mail-relatec! explanation
for the anthrax infections of Kathy Nguyen ant! Ottilie Luncigren.
The women may well have been exposed to anthrax in cross-con-
taminatec! mad! despite the apparent absence of spores in their mail-
boxes or among their personal belongings weeks afterward. The
pool of spores that they were exposed to may have been very small.
Ant! the few spores that remainec! after exposure could have been
clearer! away cluring subsequent contact with uncontaminated!
items.
These observations provide a sense of both comfort ant! un-
ease. It is clear that cross-contamination of mad! sharply cleclines
with successive placements ant! retrievals in a mailbox. After just a
few mailings, even though some big-agent might still be fount! in a
114
THE ANTHRAX LETTERS
mailbox, newly placer! letters remain largely free of particles. More-
over, the box itself becomes clecreasingly contaminates! cluring suc-
cessive mailings. Exactly where all the particles enc! up is uncertain.
But most clo not attach to the letters ant! are probably swept into
the air as the letters are withdrawn. Assuming small numbers, they
could settle into the grounc! beyonc! detection or, if indoors, be
swept from surfaces cluring later cleaning.
Still, the fact that anthrax spores are very clurable, ant! the
chance that some people are susceptible to infection from a very
small amount, is disturbing. Tiny quantities of spores from the an-
thrax letters could have fount! niches in homes arounc! the country.
While most people would appear not to be vulnerable, the fate of
Kathy Nguyen ant! Ottilie Luncigren reminds us that some people
might well be. Years from now a few anthrax spores on a piece of
long-savec! mail, or on another cross-contaminatec! surface, might
yet infect a vulnerable person. The legacy of the 2001 anthrax let-
ters could linger long into the future.
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The anthrax letters generates! a host of unexpected! finclings
ant! changer! assumptions. Conventional wisclom about anthrax
infection before the attacks was subjected! to reassessment in many
areas diagnostics, surveillance, gravity of the disease, manner of
treatment, effectiveness of transmission by mail. Perhaps the great-
est overall effect has been the nation's alterec! mincI-set about
bioterrorism. In consequence of the actual experience, almost no
one doubts the likelihood! that there will be more such attacks.
Complacency has given way to concern. Ant! no one on the planet
better exemplifies the changer! manner of thinking than Dr. Donalc!
Henderson.
