The Chewing

Chapter One: The Cluster

The page came at 2:14 in the morning, and Cal Denning was awake before the second buzz, because that was what fourteen years of field epidemiology did to a man's nervous system. He lay in the dark of his rented apartment in Decatur and looked at the screen.

EOC ACTIVATION. CALL KW IMMEDIATELY.

He called. Karen Woodruff picked up on the first ring, which was itself a data point. Karen ran the Emergency Operations Center's rapid-response desk with the calm of a woman who had personally watched three continents try to die and had learned to keep her voice level while it happened. Cal had heard her order a coffee and order an aircraft in the same tone.

Tonight her voice was not level.

"Cal. How fast can you be at the airport?"

"Forty minutes. What have I got?"

"Tennessee. Tolbert County, town called Verner. Regional referral hospital, six hundred beds, serves five counties. They've admitted three patients in the last forty-eight hours with identical presentation and I want you on the ground before it's four."

"Give me the presentation."

He heard paper. Karen still printed things out. She said she didn't trust a screen to tell her the truth.

"Onset is sudden. Patients report jaw stiffness, then jaw pain, then what the intake notes call, quote, uncontrollable mandibular activity. Chewing, Cal. Continuous chewing when there's nothing in the mouth. Progressive expressive aphasia—they lose words over roughly six to eight hours, first nouns, then everything. Pupils dilate fully and stay dilated. Non-reactive. The chart says, and I'm reading this exactly, 'pupils appear as uniform black discs occupying the entire iris.'"

Cal was already pulling clothes out of a drawer with his shoulder against the phone. "Fever?"

"None. Vitals nearly normal. Heart rate elevated late in the course."

"Rabies."

"Negative. Direct fluorescent antibody on skin biopsy, negative. Saliva PCR, negative. No prion markers, no encephalitis panel hits, no arbovirus, nothing on toxicology, nothing on heavy metals. CSF is—Cal, CSF is clean. No pleocytosis. No protein elevation. Whatever this is, it isn't inflaming anything."

He stopped moving. In his experience the human body had two responses to an invader: it fought, or it died. A clean cerebrospinal fluid draw in a patient who had lost the ability to speak meant the body wasn't fighting. It meant the body didn't know.

"Say the rest," he said. "You're saving something."

Karen exhaled. "All three patients became violent. Not agitated. Violent. Patient one, Lyle Frett, forty-four, feed store clerk, went through a set of four-point leather restraints. He bit through them. He broke eleven of his own teeth doing it and he did not stop. Patient two, Patsy Coombs, sixty-one, bit a nurse named Wanda Teague on the hand and took her thumb off at the first joint."

"Took it off."

"Amputated it with her teeth. And then, per two witnesses and the nurse herself, she swallowed it."

Cal sat down on the edge of the bed. Outside, a garbage truck was working its way down the street, a sound so ordinary it felt obscene.

"Patient three?"

"Sixteen-year-old boy, Tyler Nabors. Same course, faster. He is currently sedated with enough propofol to drop a horse and his jaw is still moving. The intensivist says he can hear the teeth from the hallway."

"Karen—"

"I know."

"Karen, that isn't a syndrome. That's a behavior."

There was a pause on the line, and in it Cal heard the whole building behind her, the low hum of the Emergency Operations Center at two in the morning, thirty screens showing thirty maps of a world that had not yet noticed anything was wrong.

"Yes," Karen said. "That's why you're getting on a plane."

The team was four: Cal, a lab tech named Priyanka Bose with two shipping cases of collection kits, a public health officer named Doug Ferrand who would handle the state and county, and a photographer from the field services branch whose job was to document everything and who threw up twice in the first six hours on the ground. They flew out of Atlanta at 5:40 into a sky the color of dishwater and were on the tarmac of a regional airstrip by 6:50, and Cal spent the flight reading the charts and not eating the breakfast someone had put in front of him.

He read them three times. He was looking for the thing he always looked for, the shared line, the one Tuesday when all of these people had been in the same room breathing the same air or drinking from the same tap. Lyle Frett lived alone above the feed store. Patsy Coombs lived on a hobby farm eleven miles out with two goats and a satellite dish. Tyler Nabors was a junior at the county high school with a girlfriend and a part-time job detasseling corn in the summer. They had no church in common, no restaurant, no water district.

What they had in common, Cal noted, was cattle. Frett sold feed to ranchers. Coombs kept eight head. Nabors's family ran a small operation on leased pasture north of town.

He underlined it and felt the old cold clarity settle over him, the thing that had cost him his marriage and most of his friendships: a problem with edges. Something he could get his hands on.

He was wrong about the edges. It would take him another nine days to understand how wrong.

Verner, Tennessee, in the last week of September, was a place of enormous gentle beauty and it made everything that followed worse. The hills were beginning to turn. Fog lay in the low fields like something poured. They drove in past a Baptist church with a hand-lettered sign about harvest, past a tractor dealership, past a diner with eleven trucks outside it at seven in the morning, and Cal looked at all of it out the window of the rental and thought, as he always thought, that the world's disasters chose their doorsteps at random and never chose the fortified ones.

Verner Regional Medical Center sat on a rise at the north end of town, a 1970s slab with two newer wings grafted on, six hundred beds serving a catchment of ninety thousand people spread over five counties of ridge and hollow. There were two ambulances at the emergency bay with their lights running and nobody in them, and a state trooper standing by the automatic doors with his hands on his belt, and a woman in scrubs sitting on the concrete curb by the loading dock with her elbows on her knees, staring at the parking lot.

Cal made the driver stop. He got out and crossed to her.

"Are you staff?"

She looked up. Fortyish, dark hair scraped back, a face that had been sturdy and pleasant a week ago and now had a strange slackness at the edges. Her name badge said T. SPURLING, RN, EMERGENCY. There was blood dried into the creases of her knuckles and a spray of it across the front of her scrubs in a pattern Cal recognized, having seen it before on other people in other years: arterial, close range.

"You're the CDC," she said.

"Cal Denning. Yes."

Tonya Spurling laughed once, without any humor in it at all, and then put her hand over her mouth as though she'd surprised herself.

"There's four," she said.

"Four?"

"Four cases. Not three. The fourth walked in on her own at four-fifty this morning, sat down in triage, and told me her teeth hurt." Tonya's eyes went past him, out to the fog in the field beyond the lot. "Her name's Dolly Wyckoff. She's a rancher out on the Bell Road. Her girl brought her."

"Where's Mrs. Wyckoff now?"

"Room four, tied down, with two orderlies on her." Tonya looked at her own bloody hands and turned them over. "That's Dr. Bhatt's blood. She took a piece out of his cheek. About the size of a plum." She said it flatly, the way people say things they have not yet been able to feel. "Mister Denning, I've been a nurse for nineteen years. I've had a man come in with a nail gun injury to the eye socket and I ate lunch afterward. You need to see the camera footage before you see the patient. Because if you see the patient first you won't believe what you're looking at, and then you'll waste time, and I don't think we have time."

She stood up. She was steady on her feet, which impressed him and worried him in equal measure.

"There's one more thing," she said.

"Go ahead."

"The girl. Dolly's girl, Rennie. She's still in the waiting room and nobody's talked to her." Tonya's mouth did something complicated. "She keeps trying to tell everybody about the cows."