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  “I don’t care,” Steadman had said. “This is an emergency.”

  An x-ray tech named Gonzalez had also gotten Steadman’s special dispensation to enter. While she was positioning the image detector under Mrs. Noguchi’s back, the patient coughed and showered her forehead and mask.

  “Please don’t do that again,” Gonzalez had scolded. “I can’t afford to catch your cold. I’m going on vacation.”

  Steadman, Pettigrew, and the nurse raced through the gowning, and once inside her room, Steadman took stock. Mrs. Noguchi was on her back, motionless, her eyes closed. He asked what the ID people thought.

  “They don’t know yet,” the nurse said. “They took cultures. We also did a portable chest x-ray. It was negative.”

  “Did they do a lumbar puncture?” Steadman asked.

  “They said neuro should do it,” the nurse said.

  “Kon’nichiwa!” Steadman said loudly. When there was no response, he stood directly over her and shouted it again, louder.

  The nurse said, “She’s completely unresponsive.”

  “I can see that,” Steadman muttered.

  He ran through a rapid neurological exam and declared her motor and sensory pathways intact.

  “There’s nothing focal,” he said, “no sign of a stroke or a bleed. This is looking like a diffuse process. Get ID back up here. I want to talk to them in person. With fever and coma, we’ve got to rule out some kind of encephalitis.”

  “Could it be from the gene therapy?” the nurse asked.

  “Of course not,” Steadman snapped angrily. “Don’t be stupid. The vector is completely benign.”

  The nurse’s eyes widened over her mask and, stung by the insult, she retreated a step.

  Steadman took no notice. “Colin, I want you to do a lumbar puncture. Ruth, go and arrange an MRI. Tell them I want it done STAT. We’ll have to send her downstairs with a mask.”

  The nurse hurried off, leaving the doctors behind.

  “I’ll get an LP kit,” Pettigrew said.

  “Send her CSF for a full serological screen.”

  “Of course,” the fellow said. “By the way,” he added, pointing to the camera under his gown, “did you want me to take any pictures?”

  “No, Colin,” Steadman seethed, “I don’t want you to take any pictures.”

  2

  Jamie Abbott was sweating, and his heart was ticking along at about one-fifty.

  “Hey, is that Derek?” he panted into the speaker.

  “Yeah, who’s this?”

  “It’s Jamie Abbott. How’re you doing? I was looking for Mandy. I hope I’m not calling too late.”

  The reply was unfriendly. “No, she’s available. I’ll get her.”

  Jamie pedaled and waited. As he leaned into the racing handlebars, sweat dripped from his forehead onto the bicycle. Ringlets of droopy dark hair fell over his eyes and he kept having to sweep them back. Growing up, his mother said he had poodle hair, and he supposed he still did. It defied styling and he always looked slightly unkempt. Adding to the impression was his heavy beard. By midday, he already sported a five-o’clock shadow.

  Amanda Alexander came on the line. “Derek said you sounded out of breath.”

  “I’m on my bike.”

  “It’s ten o’clock in Boston. You’re in Boston, right?”

  “Yeah. It’s a stationary bike. I’m doing a thirty-mile sprint.”

  “Why?”

  He kept up his furious pedaling. “I turned forty. That’s when guys start to get fat.”

  “That’ll be the day. What’s going on?”

  “I tried your mobile.”

  “I shut it off at night. I don’t see patients like you do, remember? What’s so urgent?”

  “You didn’t see the email Steadman just sent out?”

  “I told you, I power down. You pick up your emails on a bike?”

  “Why wouldn’t I?”

  “Oh, I don’t know,” she said facetiously. “What’s the email?”

  “I think you should read it. I’ll hang on.”

  He did another half mile before she came back and said, “Christ, Jamie.”

  The email was titled, Urgent Update to Study BMCH-44701, Phase 1 Trial of a Novel Gene Therapy Agent for Alzheimer’s Disease. It was from Steadman, addressed to Jamie, Mandy, and the other members of the study safety committee, with copies to various personnel at the FDA, National Institutes of Health, and Baltimore Medical. The email began, “Patient 01 a 78 yo female who was enrolled three days ago has experienced a serious and unexpected adverse event.” The message went on to describe her clinical status and lab values.

  “What do you think?” Jamie asked. “Is there any way this could be from the vector?”

  “I put that strain through every imaginable model. It’s a hundred percent non-pathogenic and non-immunogenic.” She sounded hurt. This was her baby he was talking about. “I introduced it to dozens of severely immunocompromised mice. They didn’t turn a hair.”

  “Cute.” Immunocompromised mice were hairless.

  “There’s no way it could’ve caused encephalitis.”

  “I’m not doubting you, but the patient clearly has an encephalitis of some type. We’ll know soon if anything shows up on serology.”

  Mandy said, “Steadman says her MRI was unchanged from baseline. Are there portable MRI scanners?”

  “Yeah, you noticed that too. No such thing. It means he broke isolation protocol and sent her to an MRI suite. Not smart.”

  “He wants us to meet in person on Friday. Can you make it?” she asked.

  Jamie’s bike beeped at the thirty-mile mark. “Can we talk?”

  “We are talking.”

  “You know what I mean.”

  She sounded tentative and weary. “Yes, we can talk.”

  He stopped pedaling. “I can’t believe I’m going to see you again so soon.”

  3

  Theresa Gonzalez, the Baltimore Medical x-ray tech, was in a middle seat in coach silently cursing. She had been up since before dawn to catch an early flight from BWI to Miami. As the morning progressed, her throat was getting scratchy and she was starting to feel chesty.

  She wound up saying, rather than thinking one of her “damn-its” and the elderly man in the window seat said, “Excuse me, did you say something?”

  “I apologize,” she said, hacking into a tissue. “I’m going on vacation and I think I’m catching a cold.”

  The man was pleasant enough. “Don’t you hate it when that happens?”

  “I think I know who coughed on me.”

  “Well I hope you won’t do the same to me,” he said cheerfully.

  “I’ll be careful.”

  “Are you staying in Miami?” he asked.

  “I’m boarding a cruise there.”

  “That’s wonderful. Where to?”

  “The Bahamas, British Virgin Islands, and St. Thomas. I can’t wait.”

  She coughed again but this time she was a little slow with her tissue. He must have felt some spray land on his forearm because he dabbed at it with a napkin.

  “I apologize,” she repeated.

  The man’s smile faded. He put the armrest down and pressed himself against the window.

  The stewardess who handed Gonzalez a can of soda and a bag of chips would fly on to Dallas later in the day to attend a training seminar with flight attendants from twenty states.

  That night, the window-seat passenger had dinner in Coral Gables with his three elementary-school grandkids, his daughter, a pharmaceutical sales rep with a busy schedule for the next day, and his son-in-law, an accountant who had an early tee-time in a foursome that included a Delta pilot who would fly to London Gatwick in the evening.

  Terry Gonzalez, though a little feverish, had her first on-board meal with eleven randomly assigned passengers from five states, coughing her way through the appetizers and entrée before excusing herself. In the morning she was feeling too ill to leave her cabin, but
the rest of her dinner companions disembarked at their first port-of-call in Nassau where some of them had lunch at a café next to a table of Japanese tourists on their next-to-last day of holiday. One couple stopped a Swede on the street on his final day of a business trip to see if he knew how to get to the pirate museum. Another couple asked an Italian schoolteacher to take their photo.

  And so it began.

  4

  Mandy peered through the peephole then opened the door, shaking her head in disapproval. “How’d you get my room number?”

  “I asked,” Jamie said. “I’m told I have a trustworthy face. Can I come in?”

  “I don’t think that’s a great idea. I’ll come down to the lobby bar in a few.”

  “Just give me a minute, okay?”

  She didn’t look particularly happy. “Come out of the hallway. We only know about twenty people staying here.”

  She sat on the bed, crossed her legs, and gestured at the chair. He wanted to sit beside her, to take her in his arms, to push her onto her back, but he managed to control himself.

  Fourteen years with no contact then this. It was a year ago when they found themselves in Bethesda on the same safety committee. Meeting again after all those years was one of those happenstances in the world of science—not something either of them had expected, but not totally unexpected either. He’d been aware that Steadman had chosen her virus, and she’d been aware that Jamie had done the work on the NSF-4 payload. But until then, their research orbits had been separate.

  He recalled the day he saw her at the breakfast buffet before the first general session. In his mind’s eye, the Mandy of fourteen years ago had long, wavy hair and always wore the same pair of faded, hip-hugger Levi’s in the lab. The older Mandy had a short, practical cut and a smart dress, but she hadn’t really changed all that much. Her delicate face had the same porcelain fragility, her body was still lean, the result of good genes she insisted, not exercise. She also smelled the same, like she had just rolled through a meadow of wildflowers. He never forgot her scent. It wasn’t from a bottle, it was her, and it was one of those sense memories that, to the present, triggered longings. He hadn’t known what to expect. She wasn’t someone who lived her life on social media—he had looked her up, but her online presence was light. All he could do was remember her as she had been when they were both so very young.

  Sitting across from her now, he thought this might be the very same room she had during the first safety meeting. He had a perfect memory of how she looked the morning after the night they spent together. She had flitted between happiness to the point of giddiness and remorse. She acted the same way every time they saw each other at these quarterly meetings in Bethesda, the red-letter dates on his calendar.

  “How was your flight?” he asked.

  “No problems. Yours?”

  “It took me longer to drive to Logan than fly to Reagan National.”

  “Why are we talking about travel?” she asked.

  He laughed and pushed away a lick of hair from his eye. “Warming you up with small talk.”

  “Warming me up for what?”

  He knew she knew the answer.

  “Derek didn’t seem too pleased to hear my voice.”

  “Didn’t he?”

  “He didn’t say anything?”

  She shook her head in thin-lipped discomfort.

  “He has no idea, right?” he said.

  “Of course not! And he never will!”

  “Look, I do feel guilty, in case you were wondering. I don’t know the guy, but I’m sure he’s in love with you.” He sounded sincere because he was.

  Her lower lip trembled.

  He hit her with his blue eyes and let it fly before she could say anything. “Look, I want to be with you. If you listened to your heart, I think you’d say the same thing.”

  She stood. “I told you last time I couldn’t do this anymore. That’s why I wanted to talk in the lobby.”

  “Come on, stay. I’ll be a perfect gentleman.”

  She sat again, working her jaw, dimpling her cheeks.

  “Nothing’s changed. It won’t hurt Derek. I have too much regard for him.”

  “Regard,” he said. It came out slathered in sarcasm and he regretted it.

  “Yes, regard. What’s happened between us is—was a mistake. I’m not going to let it happen again. And by the way, you wouldn’t have left Carolyn.”

  He looked out the window to the hotel parking lot. “I don’t want to talk about her.”

  Mandy had learned about Carolyn’s death years after the fact. The two women had never met, although Mandy did know Jamie was married when they began their affair. He was doing a fellowship at Harvard on brain transcription factors. She was in a lab across the hall constructing viral vectors for gene therapy. They both worked late. These things happened. One day it slipped he had a baby. Mandy blew up and that was the beginning of the end. Within a year she had moved to Indianapolis to take a junior faculty position at the medical school. There she met Derek, a biophysicist. Mandy and Jamie’s lives diverged for what might have been forever.

  “You’re right,” she said. “Carolyn doesn’t have a voice, but Derek does. I’m just saying we made the right decision back when.”

  “I would have left Carolyn if it weren’t for Emma.”

  “How is she?”

  “She’s more of a handful than ever. You and Derek were smart to keep things simple.”

  She didn’t tell him they had tried to conceive for years. “Maybe we were, maybe we weren’t. Do you have enough help?”

  “Some. Take tonight. This thing was short notice, but I was able to have her stay at her girlfriend Kyra’s house. Not my favorite of her friends, but it’s safer than leaving her home alone. Well, she wouldn’t have been alone, if you know what I mean.”

  “Poor you.” She sounded genuinely sympathetic. “Let me buy you a drink at the bar. I think we’d both do well to have a touch of ethanol aboard before the meeting starts. It could be a rough one.”

  *

  The safety committee chatted among themselves around a horseshoe table at a hotel conference room. The scheduled start time had passed, and twenty minutes later there was still no Roger Steadman. Jamie caught Mandy’s eye and pointed to his watch with an eye-roll. She reciprocated with a knowing look. Neither were great fans of the good doctor.

  Steadman finally swept in with Colin Pettigrew and took his place at the head of the table.

  “Couldn’t be helped,” Steadman said. “We were delayed leaving Baltimore by certain events. Our patient died this afternoon.”

  When the room quieted, Steadman gave his report. Mrs. Noguchi had never regained consciousness. Her family insisted on withholding heroic measures and she had succumbed to respiratory arrest that afternoon.

  An FDA official asked, “You had indicated her clinical syndrome was compatible with an encephalitis. Has that been confirmed?”

  Pettigrew spoke up. “We did a broad serological screen on samples of the patient’s blood, urine, and cerebrospinal fluid. The cause of death is Japanese encephalitis.”

  “Could you repeat that?” Mandy said, snapping to attention.

  “Japanese encephalitis. Yes, it is surprising,” Pettigrew said, “or at least it was.”

  “What do you mean, was?” Mandy asked.

  Steadman took over. “Patient One was born in Japan but she had not been there for several decades or, for that matter, anywhere else where the virus is endemic. Shortly after we received the serology results a twenty-nine-year-old man was admitted to the Baltimore Medical emergency ward with fever, vomiting, and altered consciousness. That patient is the grandson of Patient One. Presently he is in an isolation bed in our Neuro-ICU where his condition is critical. We learned from his family that two days ago he returned to Baltimore from Japan. Apparently, he is an ornithologist who had been studying wild bird populations in a remote area of Honshu Island. The JE virus is endemic there and there is some q
uestion whether he was ever immunized.”

  Jamie interrupted. “Dr. Steadman, I don’t understand how this relates to our study patient. Surely this young man couldn’t have come in contact with her. Unless my memory fails me, a grandson wasn’t on the pre-screened list of permitted visitors you filed with the committee.”

  Steadman certainly would have known this moment was coming but he still looked as if he had taken a swig of something extremely bitter. “He wasn’t on the list. It seems there was a breakdown at the level of a ward nurse. He showed up to see his grandmother. His name is similar to his father’s who is on the list.”

  Jamie glowered at Steadman and said angrily, “This was exactly the kind of protocol violation I and others warned against every time we’ve met. As recently as last month!”

  “Well,” Steadman said, looking down at his papers, “we shall endeavor to reinforce this safety aspect of the protocol for subsequent patients.”

  Jamie was incandescent, and it showed. “I don’t think there should be further enrollment, not until we’ve had a chance to perform an exhaustive investigation of this incident.”

  The director of the FDA Office of Cellular Tissue and Gene Therapies, the division responsible for the trial, said, “Dr. Abbott, tell us what investigations you’d want to see.”

  “First and foremost, I think we need to do molecular probes on autopsy samples of the patient’s brain. There’s an autopsy, right?”

  Pettigrew indicated it was ongoing.

  “Are the pathologists using full biohazard protocols?” Jamie asked.

  “They have been so advised,” Pettigrew said.

  Jamie addressed Mandy. “Dr. Alexander, can you handle this kind of material at Indianapolis?”

  “Absolutely, we have a P4 facility.”

  “Then I think Dr. Alexander ought to do the probes for the presence of her adenovirus in the patient’s tissue and see if it’s been altered in any way.”

  Steadman was manifestly tired of being a whipping boy, especially at the hands of a researcher down the totem pole. “Why are we going there, Jamie? This woman died from Japanese encephalitis. I know you’ve been beating this viral recombination drum incessantly, but this is not the time.”