Part 1 (1/2)

Yeyuka a short story.

by Greg Egan.

On my last day in Sydney, as a kind of farewell, I spent the morning on Bondi Beach. I swam for an hour, then lay on the sand and stared at the sky. I dozed off for a while, and when I woke there were half a dozen booths set up amid the sun bathers, dispensing the latest fas.h.i.+on: solar tattoos. On a touch-screen the size of a full-length mirror, you could choose a design and then customise it, or create one from scratch with software a.s.sistance. Computer-controlled jets sprayed the undeveloped pigments onto your skin, then an hour of UV exposure rendered all the colours visible.

As the morning wore on, I saw giant yellow b.u.t.terflies perched between shoulder blades, torsos wrapped in green-and-violet dragons, whole bodies wreathed in chains of red hibiscus. Watching these images materialise around me, I couldn't help thinking of them as banners of victory. Throughout my childhood, there'd been nothing more terrifying than the threat of melanoma -- and by the turn of the millennium, nothing more hip than neck-to-knee lycra. Twenty years later, these elaborate decorations were designed to encourage, to boast of, irradiation. To proclaim, not that the sun itself had been tamed, but that our bodies had. To declare that cancer had been defeated.

I touched the ring on my left index finger, and felt a rea.s.suring pulse through the metal. Blood flowed constantly around the hollow core of the device, diverted from a vein in my finger. The ring's inner surface was covered with billions of tiny sensors, spring-loaded funnel-shaped structures like microscopic Venus fly-traps, each just a few hundred atoms wide. Every sizable molecule in my bloodstream that collided with one of these traps was seized and shrink-wrapped, long enough and tightly enough to determine its shape and its chemical ident.i.ty before it was released.

So the ring knew exactly what was in my blood. It also knew what belonged, and what didn't. Under its relentless scrutiny, the biochemical signature of a viral or bacterial infection, or even a microscopic tumour far downstream, could never escape detection for long -- and once a diagnosis was made, treatment was almost instantaneous. Planted alongside the sensors were programmable catalysts, versatile molecules that could be reshaped under computer control. The ring could manufacture a wide range of drugs from raw materials circulating in the blood, just by choosing the right sequence of shapes for these catalysts -- trapping the necessary ingredients together in nooks and crannies moulded to fit like plaster casts around their combined outlines.

With medication delivered within minutes or seconds, infections were wiped out before they could take hold, tiny cl.u.s.ters of cancer cells destroyed before they could grow or spread. Linked by satellite to a vast array of medical databases, and as much additional computing power as it required, the ring gave me a kind of electronic immune system, fast enough and smart enough to overcome any adversary.

Not everyone on the beach that morning would have had their own personal HealthGuard, but a weekly session on a shared family unit, or even a monthly check-up at their local GP, would have been enough to reduce their risk of cancer dramatically. And though melanoma was the least of my worries -- fair-skinned, I was covered in sunscreen as usual; fatal or not, getting burnt was painful -- with the ring standing guard against ten thousand other possibilities, I'd come to think of it as a vital part of my body. The day I'd installed it, my life expectancy had risen by fifteen years -- and no doubt my bank's risk-a.s.sessment software had a.s.sumed a similar extension to my working life, since I'd be paying off the loan I'd needed to buy the thing well into my sixties.

I tugged gently at the plain metal band, until I felt a sharp warning from the needle-thin tubes that ran deep into the flesh. This model wasn't designed to be slipped on and off in an instant like the shared units, but it would only take a five minute surgical procedure under local anaesthetic to remove it. In Uganda, a single HealthGuard machine served 40 million people -- or rather, the lucky few who could get access to it. Flying in wearing my own personal version seemed almost as cra.s.s as arriving with a giant solar tattoo. Where I was headed, cancer had very definitely not been defeated.

Then again, nor had malaria, typhoid, yellow fever, schistosomiasis. I could have the ring immunise me against all of these and more, before removing it ... but the malaria parasite was notoriously variable, so constant surveillance would provide far more reliable protection. I'd be no use to anyone lying in a hospital bed for half my stay. Besides, the average villager or shanty-town dweller probably wouldn't even recognise the thing, let alone resent it. I was being hypersensitive.

I gathered up my things and headed for the cycle rack. Looking back across the sand, I felt the kind of stab of regret that came upon waking from a dream of impossible good fortune and serenity, and for a moment I wanted nothing more than to close my eyes and rejoin it.

Lisa saw me off at the airport.

I said, ”It's only three months. It'll fly past.” I was rea.s.suring myself, not her.

”It's not too late to change your mind.” She smiled calmly; no pressure, it was entirely my decision. In her eyes, I was clearly suffering from some kind of disease -- a very late surge of adolescent idealism, or a very early mid-life crisis -- but she'd adopted a scrupulously non-judgmental bedside manner. It drove me mad.

”And miss my last chance ever to perform cancer surgery?” That was a slight exaggeration; a few cases would keep slipping through the HealthGuard net for years. Most of my usual work was trauma, though, which was going through changes of its own. Computerised safeguards had made traffic accidents rare, and I suspected that within a decade no one would get the chance to stick their hand in a conveyor belt again. If the steady stream of gunshot and knife wounds ever dried up, I'd have to retrain for nose jobs and reconstructing rugby players. ”I should have gone into obstetrics, like you.”

Lisa shook her head. ”In the next twenty years, they'll crack all the molecular signals, within and between mother and foetus. There'll be no premature births, no Caesareans, no complications. The HealthGuard will smooth my job away, too.” She added, deadpan, ”Face it, Martin, we're all doomed to obsolescence.”

”Maybe. But if we are ... it'll happen sooner in some places than others.”

”And when the time comes, you might just head off to some place where you're still needed?”

She was mocking me, but I took the question seriously. ”Ask me that when I get back. Three months without mod cons and I might be cured for life.”

My flight was called. We kissed goodbye. I suddenly realised that I had no idea why I was doing this. The health of distant strangers? Who was I kidding? Maybe I'd been trying to fool myself into believing that I really was that selfless -- hoping all the while that Lisa would talk me out of it, offering some face-saving excuse for me to stay. I should have known she'd call my bluff instead.

I said plainly, ”I'm going to miss you. Badly.”

”I should hope so.” She took my hand, scowling, finally accepting the decision. ”You're an idiot, you know. Be careful.”

”I will.” I kissed her again, then slipped away.

I was met at Entebbe airport by Magdalena Iganga, one of the oncologists on a small team that had been put together by Medecins Sans Frontieres to help overburdened Ugandan doctors tackle the growing number of Yeyuka cases. Iganga was Tanzanian, but she'd worked throughout eastern Africa, and as she drove her battered ethanol-powered car the thirty kilometres into Kampala, she recounted some of her brushes with the World Health Organisation in Nairobi.

”I tried to persuade them to set up an epidemiological database for Yeyuka. Good idea, they said. Just put a detailed proposal to the cancer epidemiology expert committee. So I did. And the committee said, we like your proposal, but oh dear, Yeyuka is a contagious disease, so you'll have to submit this to the contagious diseases expert committee instead. Whose latest annual sitting I'd just missed by a week.” Iganga sighed stoically. ”Some colleagues and I ended up doing it ourselves, on an old 386 and a borrowed phone line.”

”Three eight what?”

She shook her head. ”Palaeocomputing jargon, never mind.”

Though we were dead on the equator and it was almost noon, the temperature must have been 30 at most; Kampala was high above sea level. A humid breeze blew off Lake Victoria, and low clouds rolled by above us, gathering threateningly then dissipating, again and again. I'd been promised that I'd come for the dry season; at worst there'd be occasional thunderstorms.

On our left, between patches of marshland, small cl.u.s.ters of shacks began to appear. As we drew closer to the city, we pa.s.sed through layers of shanty towns, the older and more organised verging on a kind of bedraggled suburbia, others looking more like out-and-out refugee camps. The tumours caused by the Yeyuka virus tended to spread fast but grow slowly, often partially disabling people for years before killing them, and when they could no longer manage heavy rural labour, they usually headed for the nearest city in the hope of finding work. Southern Uganda had barely recovered from HIV when Yeyuka cases began to appear, around 2013; in fact, some virologists believed that Yeyuka had arisen from a less virulent ancestor after gaining a foothold within the immune-suppressed population. And though Yeyuka wasn't as contagious as cholera or tuberculosis, crowded conditions, poor sanitation and chronic malnourishment set up the shanty towns to bear the brunt of the epidemic.

As we drove north between two hills, the centre of Kampala appeared ahead of us, draped across a hill of its own. Compared to Nairobi, which I'd flown over a few hours before, Kampala looked uncluttered. The streets and low buildings were laid out in a widely-s.p.a.ced plan, neatly organised but lacking any rigid geometry of grid lines or concentric circles. There was plenty of traffic around us, both cycles and cars, but it flowed smoothly enough, and for all the honking and shouting going on the drivers seemed remarkably good humoured.

Iganga took a detour to the east, skirting the central hill. There were lushly green sports grounds and golf courses on our right, colonial-era public buildings and high-fenced foreign emba.s.sies on our left. There were no high-rise slums in sight, but there were makes.h.i.+ft shelters and even vegetable gardens on some stretches of parkland, traces of the shanty towns spreading inwards.

In my jet-lagged state, it was amazing to find that this abstract place that I'd been imagining for months had solid ground, actual buildings, real people. Most of my second-hand glimpses of Uganda had come from news clips set in war zones and disaster areas; from Sydney, it had been almost impossible to conceive of the country as anything more than a frantically edited video sequence full of soldiers, refugees, and fly-blown corpses. In fact, rebel activity was confined to a shrinking zone in the country's far north, most of the last wave of Zairean refugees had gone home a year ago, and while Yeyuka was a serious problem, people weren't exactly dropping dead in the streets.

Makerere University was in the north of the city; Iganga and I were both staying at the guest house there. A student showed me to my room, which was plain but spotlessly clean; I was almost afraid to sit on the bed and rumple the sheets. After was.h.i.+ng and unpacking, I met up with Iganga again and we walked across the campus to Mulago Hospital, which was affiliated with the university medical school. There was a soccer team practising across the road as we went in, a rea.s.suringly mundane sight.

Iganga introduced me to nurses and porters left and right; everyone was busy but friendly, and I struggled to memorise the barrage of names. The wards were all crowded, with patients spilling into the corridors, a few in beds but most on mattresses or blankets. The building itself was dilapidated, and some of the equipment must have been thirty years old, but there was nothing squalid about the conditions; all the linen was clean, and the floor looked and smelt like you could do surgery on it.

In the Yeyuka ward, Iganga showed me the six patients I'd be operating on the next day. The hospital did have a CAT scanner, but it had been broken for the past six months, waiting for money for replacement parts, so flat X-rays with cheap contrast agents like barium were the most I could hope for. For some tumours, the only guide to location and extent was plain old palpation. Iganga guided my hands, and kept me from applying too much pressure; she'd had a great deal more experience at this than I had, and an over-zealous beginner could do a lot of damage. The world of three-dimensional images spinning on my workstation while the software advised on the choice of incision had receded into fantasy. Stubbornly, though, I did the job myself; gently mapping the tumours by touch, picturing them in my head, marking the X-rays or making sketches.

I explained to each patient where I'd be cutting, what I'd remove, and what the likely effects would be. Where necessary, Iganga translated for me -- either into Swahili, or what she described as her ”broken Luganda.” The news was always only half good, but most people seemed to take it with a kind of weary optimism. Surgery was rarely a cure for Yeyuka, usually just offering a few years' respite, but it was currently the only option. Radiation and chemotherapy were useless, and the hospital's sole HealthGuard machine couldn't generate custom-made molecular cures for even a lucky few; seven years into the epidemic, Yeyuka wasn't yet well enough understood for anyone to have written the necessary software.

By the time I was finished it was dark outside. Iganga asked, ”Do you want to look in on Ann's last operation?” Ann Collins was the Irish volunteer I was replacing.

”Definitely.” I'd watched a few operations performed here, on video back in Sydney, but no VR scenarios had been available for proper ”hands on” rehearsals, and Collins would only be around to supervise me for a few more days. It was a painful irony: foreign surgeons were always going to be inexperienced, but no one else had so much time on their hands. Ugandan medical students had to pay a small fortune in fees -- the World Bank had put an end to the new government's brief flirtation with state-subsidised training -- and it looked like there'd be a shortage of qualified specialists for at least another decade.

We donned masks and gowns. The operating theatre was like everything else, clean but outdated. Iganga introduced me to Collins, the anaesthetist Eriya Okwera, and the trainee surgeon Balaki Masika.

The patient, a middle-aged man, was covered in orange Betadine-soaked surgical drapes, arranged around a long abdominal incision. I stood beside Collins and watched, entranced. Growing within the muscular wall of the small intestine was a grey ma.s.s the size of my fist, distending the peritoneum, the organ's translucent ”skin”, almost to bursting point. It would certainly have been blocking the pa.s.sage of food; the patient must have been on liquids for months.

The tumour was very loose, almost like a giant discoloured blood clot; the hardest thing would be to avoid dislodging any cancerous cells in the process of removing it, sending them back into circulation to seed another tumour. Before making a single cut in the intestinal wall, Collins used a laser to cauterise all the blood vessels around the growth, and she didn't lay a finger on the tumour itself at any time. Once it was free, she lifted it away with clamps attached to the surrounding tissue, as fastidiously as if she was removing a leaky bag full of some fatal poison. Maybe other tumours were already growing unseen in other parts of the body, but doing the best possible job, here and now, might still add three or four years to this man's life.

Masika began st.i.tching the severed ends of the intestine together. Collins led me aside and showed me the patient's X-rays on a light-box. ”This is the site of origin.” There was a cavity clearly visible in the right lung, about half the size of the tumour she'd just removed. Ordinary cancers grew in a single location first, and then a few mutant cells in the primary tumour escaped to seed growths in the rest of the body. With Yeyuka, there were no ”primary tumours”; the virus itself uprooted the cells it infected, breaking down the normal molecular adhesives that kept them in place, until the infected organ seemed to be melting away. That was the origin of the name: yeyuka, to melt. Once set loose into the bloodstream, many of the cells died of natural causes, but a few ended up lodged in small capillaries -- physically trapped, despite their lack of stickiness -- where they could remain undisturbed long enough to grow into sizable tumours.

After the operation, I was invited out to a welcoming dinner in a restaurant down in the city. The place specialised in Italian food, which was apparently hugely popular, at least in Kampala. Iganga, Collins and Okwera, old colleagues by now, unwound noisily; Okwera, a solid man in his forties, grew mildly but volubly intoxicated and told medical horror stories from his time in the army. Masika, the trainee surgeon, was very softly spoken and reserved. I was something of a zombie from jet lag myself, and didn't contribute much to the conversation, but the warm reception put me at ease.

I still felt like an impostor, here only because I hadn't had the courage to back out, but no one was going to interrogate me about my motives. No one cared. It wouldn't make the slightest difference whether I'd volunteered out of genuine compa.s.sion, or just a kind of moral insecurity brought on by fears of obsolescence. Either way, I'd brought a pair of hands and enough general surgical experience to be useful. If you'd ever had to be a saint to heal someone, medicine would have been doomed from the start.

I was nervous as I cut into my first Yeyuka patient, but by the end of the operation, with a growth the size of an orange successfully removed from the right lung, I felt much more confident. Later the same day, I was introduced to some of the hospital's permanent surgical staff -- a reminder that even when Collins left, I'd hardly be working in isolation. I fell asleep on the second night exhausted, but rea.s.sured. I could do this, it wasn't beyond me. I hadn't set myself an impossible task.

I drank too much at the farewell dinner for Collins, but the HealthGuard magicked the effects away. My first day solo was anticlimactic; everything went smoothly, and Okwera, with no high-tech hangover cure, was unusually subdued, while Masika was as quietly attentive as ever.

Six days a week, the world shrank to my room, the campus, the ward, the operating theatre. I ate in the guest house, and usually fell asleep an hour or two after the evening meal; with the sun diving straight below the horizon, by eight o'clock it felt like midnight. I tried to call Lisa every night, though I often finished in the theatre too late to catch her before she left for work, and I hated leaving messages, or talking to her while she was driving.