‘How I wrote the story’: Organizing the long piece

Dancing the Barry Siegel Two-Step: (1) Deconstruct. (2) Reconstruct.

Hit the “print” key and find a comfortable chair. This week’s lesson–how to organize the long story– will take more time than previous ones.

You’re about to read a 4,700-word medical mystery story by Barry Siegel, one of the few masters of long-form newspaper writing. Barry typically undertakes narratives that capture people faced with difficult moral or technical challenges, puts you in the shoes of the protagnoist and takes you for a ride.

'How I wrote the story': Organizing the long piece

'How I wrote the story': Organizing the long piece

Today’s story, published in 1995, is part one of a two-parter that chronicled a meningitis outbreak in a small town. .The protagonist is the state epidemiologist. The dilemma is two cases of meningitis, which could have been dismissed as coincidental–and a third case, which sends our hero to the small town to battle a familiar, deadly foe.

Barry has written a detailed essay about how he organized the story, but I want you to first read the top 19 grafs, which contain the scene-setter, the scientific background you need to appreciate the yarn, and a foreshadowing of why the long journey figures to be worth the reader’s time.

By Barry Siegel

MANKATO, Minn. — The phone call Mike Osterholm received early Saturday morning, Jan. 28, was not for him all that unusual. It looks like we have two cases of bacterial meningitis, a state disease surveillance specialist was saying. Two sick teen-agers, down in Mankato, the seat of Blue Earth County.

As Minnesota’s state epidemiologist, Osterholm hears such reports fairly often. Most don’t amount to anything but isolated illness.

Osterholm was about to leave his Minneapolis home to run errands. It was Super Bowl weekend. Divorced, he had his two children over. He planned to watch the game with his 13-year-old son, Ryan.

They don’t even know if these two cases are related, Osterholm told himself. They don’t even know if it’s the same bug.

Still, he hesitated.

At 42, Osterholm had been Minnesota’s top medical sleuth for 11 years. He’d developed a national reputation as one of the country’s premier experts in tracking and controlling infectious disease. “If anyone is going to pay me a compliment when I die,” he liked to say, “I hope it’s that I learned to think like the bugs do.”

Osterholm believed he understood the bug–Group C Neisseria meningitidis– that caused most outbreaks of meningococcal disease. He’d written about it, he’d studied it, he’d fought it. He knew how it behaved. He thought of it as an old, familiar relative.

But the familiar relative had been acting strangely of late.

For reasons unknown, Group C outbreaks had risen sharply since 1991. On Osterholm’s desk that weekend, newly arrived, sat the Feb. 1 edition of the Journal of the American Medical Assn. In it, an article described 10 such outbreaks in the United States in the past 2 1/2 years. There had been only six in the eight years before that. The rate had quadrupled.

“An emerging threat. . . ,” JAMA called these outbreaks. “One of the most feared public health emergencies, in part because of the disease’s ability to strike, seemingly at random, previously healthy persons, killing one of every seven affected.”

Meningococcal disease, Osterholm knew, was one of the few that could take a healthy person and, by infecting the bloodstream or the lining around the brain and spinal cord, kill within six hours. You could go to bed with flu-like symptoms and never wake up.

Osterholm didn’t want to over-respond to the news from Mankato, didn’t want to foment panic. He also, though, didn’t want to underestimate the problem.

Let’s get blood samples up to the state lab, he told his staff that Saturday. Let’s get more clinical information about the patients. Let’s set up a conference call. Let’s contact the schools down there.

Then he waited for his old familiar relative to show its hand.

The wait lasted just one night. On Sunday morning, Osterholm’s phone rang again. The Mankato hospital now had a third case of meningitis. And the state lab now had a result: The first two cases involved the same bug–Group C Neisseria meningitidis.

Dammit, Osterholm thought. Here we go. We’ve definitely got something now.

What he had, in fact, was an outbreak unprecedented in all the scientific literature. Before it ended six weeks later, the Neisseria meningitidis bacteria would behave in Mankato in ways never before reported. In turn, the Minnesota Health Department and the Mankato community would wage a battle never before attempted. There would be moments of panic, accomplishment and tragedy. Most of all, there would be uncertainty. When the bacteria’s siege finally abated in mid-March, it would remain unclear just who had won.

Armed with state-of-the-art tools, guided by years of experience, the experts could study, poke and assault the bug, but they could not explain or master it. Forced to navigate uncharted waters, they could not know whether they were choosing the right course. In the end, they could not even say for sure whether they’d had any impact at all.

Of only one issue was Osterholm utterly certain: “Mankato is not the exception,” he declared. “It will be the norm.”

– – – – –

Now Barry explains his long-form organization process. You can apply its best lesson–first, deconstruct; then, reconstruct–to any size or kind of story:

For me, the first key to successful organization and writing is in the reporting. As I ride airplanes and conduct interviews, I try always to keep in mind what I will be doing when I get back to my desk, and what I will need. What I will need are characters, points of view, scenes, a conflict, a storyline and–above all–details. When I interview, I keep asking people to walk me through their experience minute by minute. I try to get them to recollect particulars, to not talk abstractly, to not talk in cliches.

Flying home, running through everything in my mind, it all usually feels compelling.

Then I sit down at my desk and find myself staring at a three-foot-high pile of interview notes, clips, articles and briefs. Suddenly my compelling story looks like–well, a three-foot-high pile of notes. Boring, chaotic notes with no meaning or shape. Sitting down at my desk after returning from a reporting trip is for me always a daunting experience.

So the first thing I try to do is distill that three-foot-high pile into its essence.

That’s what I did when I began to organize the meningitis story. It is not an exciting process. It is drudgery. But for me it is absolutely necessary drudgery.

I typed my notes. Then I typed several types of ”indexes” or summary distillations of my notes. At this point I’m trying to boil everything down so I can get my mind around the story.

Chronology, characters, points of view, issues. Those are the elements in my raw material that I want to identify and isolate.

Chronology was obviously essential to the meningitis story, so I built one. Drawing from my dozens of interviews, from hospital records, from local newspaper accounts, I blocked out each day of the meningitis siege, and listed all the key things that happened on that day. That was my basic story line, the narrative spine on which I would try to hang a lot of baggage.

Next I typed up a sort of index of my interviews, listing next to each person key bits and shorthand references to what they said. With yellow highlighter and red pen, I identified on this sheet which people were at key scenes or knew particular parts of the story. I identified, for example, which ones had experienced John Janavaras’s death directly, which ones had seen examples of panic and rumors, which ones had handled Joe Kratzke or Ryan Pitt, which ones had attended the vaccination clinics.

Next, drawing from this highlighted index, I made notes in the margins of my chronology, pointing out which folks to turn to when it came time to tell a particular part of the story.

Next I highlighted critical passages in the key JAMA articles that had recently proclaimed these meningitis outbreaks ”an emerging threat.” Drawing from the highlighted sections, I typed up a summary of the Mankato outbreak’s context.

Next I typed up a sort of primer about epidemiology, and about the meningitis bug. I knew I would need to take readers into a somewhat technical world, but I felt I could make it a fascinating world if I explained it with clarity and precision. (I’ve long been an appreciative reader of medical detective stories such as the Annals of Medicine pieces by Burton Rouche in The New Yorker.)

Next I typed up a summary of recurring themes and issues underlying the narrative. Some of this came from medical journal articles, some from my interviews, some from ”experts” who I knew would not appear in my story, but would nonetheless inform it. Themes like: ”The microbe as emerging threat.” ”People today don’t recall epidemics, people expect modern medicine to protect them.” ”Mankato’s shattered sense of safety.” ”Mankato’s sense of vulnerability and powerlessness.” ”Uncharted waters, unprecedented events.” ”Rumors and panic.” ”The science is thin.” That’s all I wrote in this summary, just a few lines, but together with the chronology it would serve as the primary guide when I began to construct the story.

When I was done typing up indexes and summaries, I had reduced the boring chaotic three-foot pile of notes into a few sheets of paper.

Then I just sat with those few sheets of paper before me, and tried to imagine my story. No computer, no pad of paper, no pen; just thinking at this stage. What I tried to imagine was not a research project or a newspaper article, but rather, a nonfiction short story. A nonfiction short story with character, point of view, plot, conflict.

I reread the few pages, shuffled them, reread them, thought. Eventually, I began to feel I was mastering all the information I had, that I was getting my mind around the pile of notes. When I could scroll through all the events and details in my mind, without consulting my notes, I was ready to sketch out an outline.

Only now did I pick up a pen. I’d deconstructed, now I would reconstruct.

Structure is so critical in storytelling. How to weave everything together-basic plot, information and context, character, details, point of view? Passages that drag badly in certain places can really take off if located properly within the story. For instance, the ”dull dry” stuff about meningococcal disease and epidemiology doesn’t have to be just ”necessary important” information to slip in amidst the punchy narrative. If I can set it up right, such background context becomes fascinating; it doesn’t slow down the story but rather enhances it, makes it all the more exciting, by explaining to readers the meaning and import of what’s happening.

Where to stop the narrative, where to pull up and explain and lay in your context–this was a large part of what I considered as I built the outline.

Point of view was also a large part. I knew the state epidemiologist Mike Osterholm would be the key point-of-view character; that’s how the story was originally conceived. But I would need to cut away from him, momentarily to various Mankato citizens, and for longer stretches to those stricken by the disease.

Which of the stricken? I didn’t want to re-create seven or nine cases, for the details would start to repeat, the drama diminish. Joe Kratzke was an obvious choice, because he was the first to fall ill; he starts the story. I chose Ryan Pitt both because he’s such a great spunky little boy, and because it was with him that the bug jumped the fire line. Of course I needed John Janavaras, because his was the one death.

As I built my outline, as I shifted points of view and stopped to lay in context, my goal was always to let the broader themes arise from the narrative. I didn’t want to stop and quote experts, didn’t want to stop and lecture directly to the reader. Above all, I wanted to stay within the story. My aim was to let Mike Osterholm and others reflect on or wrestle with the broader issues as they battled the Mankato outbreak.

Sometimes I really have to bend and twist to stay within a story, but not with this one. Through Osterholm’s point of view I could get both the Mankato story and the larger context. I didn’t even have to step out of the story to describe the JAMA article that proclaimed these outbreaks as an emerging threat. Osterholm, it turned out, had a pre-publication copy of that JAMA article sitting on his desk the morning he first got a call from Mankato.

I also didn’t really have to struggle about where or how to begin my story. I knew I’d open with Osterholm receiving a phone call, getting the first word about something strange in Mankato.

From there, I wanted quickly to do a few things:

–Establish the conflict-Osterholm’s battle with a foe he considers ”an old familiar relative.”

–Establish what was at stake here-this disease could kill healthy people within six hours, and outbreaks of this disease had risen sharply, mysteriously, since 1991.

–Avoid a traditional nut graf that proclaims universal meaning and reveals the ending.

Instead, I wanted to establish the ”nut” in the form of a dilemma or crisis my main character is about to face. Then I wanted to set him off to face it; I wanted, in other words, to turn into the story.

In truth, after distilling my notes, building my outline and establishing the opening, I found the rest smooth sailing. I often go through many drafts in which I rearrange entire chunks, drastically changing the structure, trying to find the right form in which to tell the story. Not so with the meningitis story. I wrote it in one draft, doing only some basic cutting and line editing. Then I reread my whole three-foot-high pile of notes to see if I’d left out critical stuff, made a few additions/fixes based on that review, and was finished. Rarely does it go so smoothly, certainly not with a 10,000-word article.

Why this time? You could say it’s because I organized so vigorously, but I always do that. I think it’s because the elements I needed for good storytelling were present from the start in this particular situation. For once, I’d chosen a project free of the customary pitfalls and roadblocks and unfortunate hard right turns. Nothing blew up on me, nothing turned sour, nothing clanked and rattled. I only wish it would happen more often.

– – – – –

Now we return to the remainder of the narrative, which starts with the first victim:

The Basketball Player

When Joe Kratzke arrived home at 10 p.m. on Thursday, Jan. 26, he told his father he felt “kind of achy” and wanted to stay home from school part of the next day. Kratzke, 17, a lanky 6-foot-2 and 175 pounds, was the shooting guard on Mankato West High’s basketball team. They had a game Friday night. He wanted to be rested.

His father, Gary, was irritated. If Joe didn’t feel well, why had he stayed out so late?

It was a challenge for Gary. At 45, he had to run the family’s retail clothing store while rearing three children. His wife, Julie, had died of cancer almost exactly a year before. Besides Joe there was Jill, 11, and Justin, 9.

OK, he told his son. But you’ve got to spend part of the day at school or they won’t let you play.

The next day, Joe went to school from noon to 3 p.m. When his father came home at 5:30, he found Joe sleeping. He woke him and gave him a bowl of soup. Joe was sluggish. He had a headache.

Mankato West requires its varsity players to be at the gym in time to watch the B game, so Joe drove to the school at 6. Gary followed soon after. Sitting in the stands looking at his son as he walked by, he noticed that Joe had rashes on the inside of both arms.

In warm-ups, Joe appeared lethargic. He, Gary and the coach conferred. How do you feel? Gary inquired.

By then, Joe’s head was exploding with pain every time he ran, every time his foot hit the ground. His neck felt sore, his legs stiff and tired. He knew he couldn’t play, but didn’t want to say so. Finally, he had to. “Well, this headache is pretty bad,” he allowed.

As Joe sat on the bench watching the game, the rash on his arms began spreading. He grew faint, and pale and scared. At halftime, he decided he wanted to see a doctor right away.

Accompanied by his girlfriend, Joe left the game at 8:30 and drove to nearby Immanuel-St. Joseph’s Hospital. Walking the last 100 feet across the parking lot to the outpatient lobby, he vomited six times.

At a glance, nurse Kelly Duncanson knew to get Joe to the emergency room. There, because of the severe headache, Dr. Andy Boggust ordered a CAT scan, which revealed nothing unusual. The ER doctor considered: Joe’s temperature was rising. The rash indicated bleeding under the skin. It looked as if they were dealing with an infectious process.

Boggust ordered a spinal tap. That revealed cloudy spinal fluid–it normally is clear–and spinal fluid pressure off the scale. This, the doctor now knew, was a disease process affecting the brain lining.

By then, Joe had started sinking into a dulled, semiconscious state. Dr. Peter Nolan, the emergency room’s on-call pediatrician, had to rake his knuckles hard across Joe’s chest to get any response.

Joe’s cloudy spinal fluid could mean various types of infection, not all terribly serious. But Joe’s rash troubled Nolan. It was the kind they saw in meningitis.

Large Group C epidemics occurred in the United States up until 1944; an estimated 2,600 cases and more than 370 deaths still occur each year. Most arise in the fall and winter; most affect school-age children and young adults, probably because their immune systems are still developing.

Until a few years ago in Mankato–a small river town of 31,000 about 80 miles south of the Twin Cities–doctors used to see 10 or more meningitis cases a year. Then, in the mid-1980s, they started giving infants a new vaccine for Type B influenza, which involves a similar bug. Ever since, they hadn’t seen much meningitis at all.

But tonight they were, Nolan surmised. Fever, vomiting, headache, stiff neck, confusion, sleepiness, irritability and rash–these were the classic symptoms.

Admitting Joe to the critical care unit, the doctor ordered massive doses of penicillin and a second antibiotic. He knew, however, that the medicine might not save Joe. Even if it killed the bacteria, the dying bugs would keep producing deadly toxins.

Nolan took some comfort from Joe’s elevated white-cell count. Good, he thought. That means he still has soldiers fighting for him.

Called by Joe’s girlfriend, Gary Kratzke rushed to the hospital, where he found his son barely conscious. To him, Joe looked like a vegetable.

For nearly half an hour, the father talked to the son, sometimes eliciting brief responses. Then Joe started declining before Gary’s eyes. Asked by a nurse, he could not speak his last name. Within minutes, Joe was in a coma. When Nolan knuckled him in the chest, he didn’t respond at all.

Gary felt himself unraveling. I can’t believe this is happening, he thought. I was just talking to him.

Shortly after midnight, Nolan took Gary aside. “This is a very frightening case,” the doctor advised. “This is life or death. Joe could die.”

At 2:30 a.m., just before leaving for home and his two younger children, Gary studied his son. Joe, he observed, looked just like his wife did when she passed away.

The Bandleader

It was not until early Saturday that the hospital staff realized they might have two meningitis cases on their hands.

Sara Kleinsasser, a 17-year-old Mankato West High bandleader, had arrived at Immanuel-St. Joseph’s more than two hours before Kratzke. When admitted at 6:13 p.m. she’d been feverish, limp, delirious and covered by a bruise-like rash. Doctors had labored for hours to stabilize her plummeting blood pressure, but had not fixed on a definite diagnosis.

Reporting for duty at 7 on Saturday morning, bedside nurse Maurine Corcoran and nursing supervisor Mary Guentzel heard about both Joe and Sara.

They decided they should call Jane Schwickert, the hospital’s infection control nurse practitioner. By 9:15 a.m., Schwickert was at the hospital, peering over Sara and Joe. Both were in respirator isolation, both were comatose. Sara’s blood pressure was dropping fast.

If this was the start of an outbreak, how to control it? Should they give antibiotics to all close contacts of these patients? Which one? What was the protocol?

Uncertain, feeling panicky, Schwickert decided to phone the state Health Department in the Twin Cities. Within two hours she was on a conference call, talking to Osterholm.

Schwickert felt impressed and reassured. Osterholm had a lustrous national reputation. He sat on countless committees and review boards, he projected unflappable assurance, he’d even tried twice–vainly–to swim the English channel. Reared in Iowa by an Irish mother and a Swedish father, he’d gone straight from college to the state Health Department, working there while he earned a master’s degree in environmental health and a doctorate in epidemiology. He’d been tracking, writing and lecturing about bugs for 20 years.

On the phone, Osterholm led Schwickert and other Mankato officials through all the possibilities. Epidemiology 101, he called it. Much came from medical journal articles he’d co-authored.

Timing was important, he explained, in controlling both the outbreak and community panic. People should be careful, but not frightened. The bug spreads not through the air but through secretions of the nose and throat. So avoid deep kissing, don’t share food or beverages, don’t spray others with droplets from coughs or sneezes. But you can go to large gatherings such as sporting events.

They didn’t know if it was really the same bacteria yet, Osterholm pointed out. They’d have to wait and see what developed. If they had a third case, the state would come down. Meanwhile, he wanted blood samples sent overnight to the Health Department’s lab in Minneapolis for analysis.

For a time the next morning–Super Bowl Sunday–it looked as if Mankato might not be facing an outbreak after all. Joe and Sara still lay in the hospital’s critical care unit battling for their lives, but they’d started to stabilize, and no new cases had arrived. After checking with the hospital, Schwickert went to brunch. Alice Weydt, the hospital’s director of patient care, went to church. Osterholm’s thoughts turned to the Super Bowl.

Then, close to 11:30 a.m., an ambulance rolled up to the emergency room door. Inside, flailing, throwing his arms about, was Jon Boyer, 17, a Mankato West student.

He’d had a sore throat all Saturday afternoon during his work shift at Jake’s Stadium Pizza, his parents reported. At 8 p.m., he’d gone to a friend’s house, but shortly after, not feeling well, he’d come home and climbed into bed. By 10:30, he was vomiting and feverish. By 3 a.m., he was delirious. By morning, his neck was so stiff he couldn’t touch his chin to his chest.

Boyer had the classic symptoms of meningitis.

By the time Osterholm heard the news, he’d already received a call from his state lab. The samples from Mankato had arrived. Both looked to be Group C, the type most often involved in outbreaks.

Well, Osterholm reasoned, at least there’s something to do now. A relatively rare vaccine did exist for Group C. It was not recommended for routine, general use because it didn’t work with infants under 2, and didn’t work with all types of the bug. It would work in Mankato, though.

By midday, Osterholm was consulting with other state health officers who would be fighting the outbreak with him–among them Mike Moen, Kris Macdonald, Mary Sheehan, Craig Hedberg and Aggie Leitheiser.

By late afternoon, Osterholm was driving to Mankato.

He didn’t know of any outbreak in which public health officials had started as quickly as they were. They had, he thought, a real chance of affecting the outcome in ways not normally seen. This is going to work, he told himself. This we’re going to handle.

Then, driving on, he reconsidered.

Their foe was silent, cunning and invisible. Their foe was agent for the most formidable power of all–Mother Nature. Whatever they did, Osterholm had to admit, people were going to get sick, even end up blind or brain-damaged. Whatever they did, one in seven of their patients would likely die.

Battle Plan

We live in an age that promises an illusory safety, Osterholm likes to point out.

Most people grew up without much fear of or exposure to infectious diseases. Polio, tuberculosis, scarlet fever, influenza epidemics–they’re all far in the past. So the public generally assumes modern medicine has licked infectious microbes, at least those that aren’t obscure, exotic refugees from distant rain forests. If you get sick, unless it’s something like cancer, you go to a doctor, you take medicine, you get better.

That, Osterholm knows, just isn’t so. The world as he sees it looks far more perilous, its human inhabitants far more vulnerable. Microbes are continually evolving, and continually trying to consume our bodies. Malaria, AIDS, TB, E. coli, hantavirus, the so-called “flesh-eating” Group A strep–to epidemiologists, facing them is like trying to stop a juggernaut. Or, rather, slow it: Each year, about 100,000 people in the United States die of bacteria-induced toxic shock.

The microbes aren’t spreading by evolution alone. Poverty, population explosion, disrupted ecosystems, international commerce–they all play a role. So, too, Osterholm argues, do relaxed surveillance and a collapse of the public health infrastructure, because of chronic underfunding and complacency in the age of antibiotics.

Driving to Mankato, reflecting on this situation, Osterholm seethed with frustration.

Microbes were sitting in the Twin Cities International Airport terminal that dwelt in African forests two days before. Almost 80% of the produce consumed in the United States was coming from developing nations. Minnesota, the whole country, was being bombarded from the outside. But scientists lacked the funds even to study properly what was happening.

The country’s budget for disease surveillance was $75 million, and most of that went to AIDS, TB and sexually transmitted diseases. They had maybe $20 million for everything else, and Congress was talking about cutting funding for the Centers for Disease Control and Prevention and its infectious disease program. When something big broke, there just was no infrastructure to respond. It was like trying to run Chicago’s O’Hare Airport with tin cans and string.

What he could do with the movie “Outbreak’s” $45-million budget, Osterholm fumed. Instead of Dustin Hoffman racing about in a helicopter, he had a crew of public health staffers scrambling to locate enough syringes. Instead of blank studio checks, he had staffers buying medicine by writing personal checks and pleading for $20,000 purchase orders.

Osterholm pulled into Mankato in the late afternoon. He couldn’t help but relax a little in such a friendly, unpretentious place. Set in a wooded valley where the Minnesota and Blue Earth rivers join, Mankato is both a college town, home to Mankato State University, among other schools, and a processing center for a grain and livestock region.

There was good news for Osterholm at Immanuel-St. Joseph’s.

At 3 p.m. Sunday, Gary Kratzke, encouraged by the hospital staff, had started talking to Joe, trying to draw a response from his comatose son. “Joe, can you hear me?” he’d repeated, standing at his son’s bedside. “Joe, say something.”

“What do you want me to say?” Joe had finally answered, rolling his eyes. Even the doctors and nurses had cheered.

He’s coming out of it, the hospital staff told Osterholm. Sara also was improving.

A 6 p.m. meeting of Mankato officials, called by Osterholm, drew a standing-room crowd of 40 to Immanuel-St. Joseph’s education room. All sorts were there–hospital staff, private practice doctors from the Mankato Clinic, local politicians, county health officers, Mankato School District officials.

Osterholm flourishes before such gatherings; he is a polished public speaker. Educating and mobilizing communities is as central to his job as is studying bugs in the lab. It is also as tricky.

Osterholm stood before the Mankato crowd as an outsider, as an agent of the state. He was talking to medical doctors not inclined to take instruction from a Ph.D. So rather than direct, he guided toward consensus. Here’s the situation, here are the options, here’s what we know and don’t know, he said. We’re here to help. What do you want to do?

It worked. Those listening were impressed by his matter-of-fact knowledge and appreciated the fact that he wasn’t imposing his will. Perfect, thought Al Neely, the nurse manager of emergency and outpatient services. Super-impressive, thought Jerry Crest, the hospital’s administrator.

Rather than inspire confidence in science, Osterholm had inspired confidence in himself. Later, he’d insist this made him uncomfortable, but in truth, it was needed, if only to curb panic. The science, after all, was not nearly as sturdy as Osterholm’s poised performance.

In the days to come, they would be making decisions amid much uncertainty. They would have to move without the necessary information, before they had test results. They would have to act without knowing whether it was the right course.

The epidemiological literature suggests “extraordinary public health intervention” in meningitis outbreaks, including early “intensive selective vaccination campaigns.” But “selective” is the operative word.

What segments of the Mankato community should be targeted for the vaccine? Since the disease usually affected youngsters who hung out together in places such as schools, should everyone from kindergarten through Mankato State University get vaccinated? Or just the district’s junior and senior high students? Or only Mankato West students?

Should the antibiotic rifampin also be given? It sometimes was in meningitis cases, but its efficacy was uncertain, and it had various side effects. What’s more, the antibiotic didn’t protect you; rather, it reduced the chance of transmission. How to decide, when there was no broadly based study to show it made a difference at all?

Financial considerations couldn’t be ignored–each vaccine costs $22. But the need to define and limit the response rose from more than just monetary issues. If they aimed too broadly, they’d be wasting time and diverting resources from the high-risk groups that most needed help. It would take a week or more to arrange 30,000 vaccines. Doing so, Osterholm felt, would be plain unethical. They couldn’t delay getting the vaccine to those at highest risk. It was a triage issue; you treated those most in need first.

Osterholm also feared the slippery slope. If they started vaccinating people without a clear scientific basis, it was fairly easy to ask, why limit it at all? Why not vaccinate all of Minnesota? Already, seeds of panic were growing in Mankato. The TV stations were saying you needed to check your children every hour at night, they could die if symptoms were ignored. But it was January in Minnesota; there were lots of kids out there with flu or strep throat.

We need a rational reason for picking who we’re going to vaccinate, Osterholm told those gathered Sunday evening.

The trouble was, a rational reason required an understanding of what linked those who’d gotten sick. That still wasn’t apparent. The victims weren’t close friends, did not play on the same teams, did not sit in the same classrooms.

So Mankato officials and Osterholm’s staff mapped a plan based on what they did know. All junior and senior high school students in the district would get vaccinated Tuesday morning. They would not, however, be given rifampin.

Osterholm marveled at this small town’s mutual trust, enterprise, sense of community. Even as the meeting ended at 9:30 Sunday night, the hospital staff was scrambling to set up a hot line to handle calls from the community. School administrators were laying plans to distribute parent permission slips. Community relations specialists were herding reporters into a news conference. And Osterholm was on the phone to Connaught Laboratories in Swiftwater, Pa., ordering 4,000 doses of the Group C vaccine to be airlifted for Monday delivery.

The next 48 hours passed in a blur.

By 7 on Monday morning, Immanuel-St. Joseph’s had a fourth meningitis patient–Casey Houston, a 16-year-old West High wrestler, whose parents thought he had the flu until, at 6:30 a.m., they read about the outbreak and discovered their son’s neck was so stiff he couldn’t bend it. By midmorning the hospital had a fifth case–an unidentified 64-year-old woman who’d been admitted on Saturday, but hadn’t been diagnosed until now.

By midday, the media satellite trucks had rolled into town, along with the first panicky rumors. By afternoon, a half-dozen school districts had canceled sporting events with Mankato teams. By day’s end, dozens of nervous Mankato citizens had crowded into the Immanuel-St. Joseph’s waiting room with flu-like symptoms, and more than 1,000 had called the hospital hot line.

The outbreak is not likely to spread beyond Mankato West High, Osterholm reassured the 300 citizens who attended a Monday evening community meeting in the school’s auditorium. He did not recommend restrictions on travel. The risk is relatively small. “The real danger is not meningitis, but meningitis phobia,” he said.

The vaccinations began Tuesday at 8:15 a.m. in the Mankato West High gym, directed by Nancy Meyer and Mary Gleason of the Blue Earth County Health Department. Within 34 minutes, 60 county health workers had inoculated more than 1,000 students. Within six hours, traveling by bus from school to school, they’d immunized the entire target group of 3,300.

That evening, much of Mankato collectively sighed in relief.

They had acted; they had countered the attack. They’d apparently saved five people–all the patients were improving–and the bug had not struck again.

As Wednesday, then Thursday, passed with no new cases, the media trucks pulled away, the calls abated. Although they knew the vaccine wouldn’t take effect for 10 days, even the medical professionals began to feel pleased.

Nurse practitioner Schwickert went skiing Thursday night. School Supt. David Dakken began a rough draft of a thank-you letter to the medical community. We’ve licked this, hospital chief Crest told himself. “We are very definitely encouraged,” Osterholm informed the local newspaper on Thursday.

As a hospital meeting ended at 7:30 the next morning, Friday, Feb. 3, Crest turned to Schwickert.

“I feel real good,” he said.

“We’ve taken care of all these, and haven’t lost one,” Schwickert agreed.

At that moment, a nurse, interrupting, leaned across the table. “Have you heard?” she said. “They’ve just brought another kid into the ER.”

The Hockey Player

John Janavaras, 15, a scrappy, undersized Mankato West High hockey player who’d hustled his way onto the varsity team, had skated strongly during practice the day before. He’d felt safe enough to share a pop bottle with a friend after practice, despite public warnings. He’d felt well enough at 5 p.m. to make weekend plans to attend a hockey game. He’d felt hungry enough to call his mom and ask about supper.

An hour later, though, he was home in bed with a 102-degree fever, complaining of body aches. Classic flu symptoms, thought his mother, Linda, a Mankato-area gift shop owner. His friend and teammates had the flu days before; now it was his turn. She called the coach to say John wouldn’t be at practice the next day.

Throughout the night, the mother checked on her son. Several times, John woke up. At 3 a.m., Linda gave him medicine for his fever. Not until 6 a.m., when she found her son covered with a rash, did she realize he likely had meningitis, even though he had been vaccinated three days before.

By the time she got him to Immanuel-St. Joseph’s shortly after 7 a.m., he was too weak to walk. She rolled him through the emergency room door in a wheelchair. Still conscious and coherent, John asked his mother to turn on a television. Neither mother nor son realized just how sick he was.

The medical staff understood, though. Nurse manager Al Neely, observing the grape-colored bruises covering John’s face and chest, sensed this boy was in trouble. When the initial lab work came in, Neely knew it.

Right on a slide, on the lab smear, he could see the microorganisms in John’s blood that you’d usually have to grow out in a culture. You usually saw that only at a post-mortem. You don’t expect to see that in a person who’s talking to you.

If there were so many microbes in his blood that they could be seen, Neely knew that John’s body had to be teeming with poison. John was awake, John was still talking to the doctors. But he’d need a miracle to survive.

The Neisseria meningitidis bacteria can be found residing benignly in the nasal passages of 1% to 4% of the population. For reasons unknown, the bug sometimes turns deadly and travels from the nasal passages to the bloodstream. Usually the immune system manages to eradicate it from the blood. The bug then goes to the spinal fluid and inflames the linings of the brain and spinal cord, causing meningitis.

As terrifying as that is, it’s better than if the bug stays in the blood. Meningococcal septicemia–a blood infection–is much harder for doctors to treat. Even if they can kill the millions of rapidly multiplying bacteria in the blood with massive doses of antibiotics, they can’t stop the dying bacteria from releasing their toxin into the blood, where it is carried to cells, tissues and organs, eventually destroying the entire human system.

That’s what was happening to John. The bug was in his blood, not his spinal fluid. His small vessels were leaking, his pressure was dropping, clots were forming. He was in shock, his organs unable to get enough oxygen.

By then, John’s father, Basil, a business professor who’d been up in the Twin Cities, had reached the hospital. Shortly before 9 a.m., John told his parents he couldn’t breathe. Minutes later, the hospital staff announced a “code blue” and began resuscitation efforts.

Two doctors called out instructions to critical care nurses and a respiratory therapist. Anesthesiologists monitored the airway and pumped oxygen. Nurse manager Neely–thinking of his own 16-year-old boy, who plays football at Mankato West–administered chest compressions. The hospital’s vice president, Annette McBeth, after looking at John, warned the chaplain to get ready.

Linda and Basil couldn’t believe this was happening. John was sick, but dying? Why? How? John was such a hustler, John had so much heart and soul.

Twice, three times, the staff got John’s heart beating. He had no blood pressure, though, so he couldn’t get the oxygen needed to keep going. After working on him for more than two hours, doctors declared John dead at 11:39 a.m. As the news spread, doctors, nurses and administrators wept along with the parents.

“I didn’t have a clue,” Linda told a reporter days later. “I never imagined he would die. . . . No one took this (outbreak) seriously until John died. But these bugs, they do kill. . . .”

The medical staff was no less startled. They’d heard Osterholm describe the probabilities, but such vulnerability hadn’t fit with what they’d held as true about their world. After saving five patients, they thought they’d be ready for another. They thought they were aware, and prepared.

They were not, McBeth now realized with dismay. To see someone rapidly decline as John did, second by second–she couldn’t believe their efforts weren’t working. That they were going as fast as they could, but couldn’t go fast enough–it shook her to the core. She couldn’t avoid feeling that, somehow, they’d all failed.

Those outside the hospital were even more shocked. That doctors and hospitals cured you when you fell sick had always been an article of faith.

The afternoon of John’s death, Mankato West High Principal John Barnett agonized over how to announce it to his student body. “If you need to cry, cry,” he finally urged over the public address system minutes after the lunch hour. “If you need to be with somebody, come to the auditorium.” Hundreds did just that, hugging, weeping, gathering in small groups.

“As lay people,” school Supt. Dakken would later observe, “we still hadn’t grasped the swiftness and seriousness of the disease. To me, with John’s death, it now hit home. I realized, however good you are, whatever your resources, regardless of what you do, you can’t avert tragedy. . . . I hadn’t realized that.”

Less than half an hour after John’s death, calls started flooding the hot line. They would be dealing with community panic, deflated hospital staffers quickly realized, as well as a rampant bug. It was a whole new ballgame.

Just then, news reached them that minutes before John died, a very sick 3-year-old boy had arrived at the emergency room with all the symptoms of meningitis. To McBeth, it now felt as if hell was breaking out. To Schwickert, it felt as if the world was collapsing.

To Osterholm, though, it felt as if they were traveling on a well-mapped road. The 3-year-old was the seventh case. One in seven had died, just as he’d warned. His old familiar relative was operating precisely by the book.

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