Zoo Operates Under Gaps In Oversight

Edward C. Ramsay, a veterinarian at the University of Tennessee and the Knoxville Zoo and once a competitor with Spelman for a job at the National Zoo, reviewed Nancy's records at the request of The Post.

"Especially knowing the end, it's kind of like reading the story of a train wreck, watching it move uncontrollably to a horrible end," Ramsay said.

Ramsay also said that because Nancy was on immune-suppressing steroids, "that probably sped up the disease process."

Nancy's necropsy concluded that the extensive presence of the disease throughout the elephant's respiratory tract meant there was "a high probability" that she had spread TB into the environment. Spelman, nearly two months into her tenure as zoo director, was notified immediately, Nichols said.

But the results were not announced publicly.

The day after Nancy's death, in an e-mail to top officials with the subject heading "TB in elephants," Spelman provided a range of "recommendations for immediate actions." For the zoo's public affairs staff, she recommended research on TB on the Internet and in news archives but no calls to other zoos "since we do not have a firm diagnosis."

She continued: "Essentially, Nancy could have had this infection for 40 years, and it only began to spread as she became otherwise debilitated. Or did the immune supressing drugs play a role? We'll never know the answer to this question for sure.

"I do not foresee that we would call a press release to 'announce' this situation unless our decisions affect public viewing of the elephants and other animals in the elephant house. But I intend to be open and informative about it when the topic arises." the e-mail said.

On Sept. 16, 2000, Montali told Spelman in an e-mail that Nancy had bovine TB, a form that is less infectious than the kind usually passed between humans.

On Sept. 18, Spelman advised zoo staff in an e-mail not to bring up Nancy's TB during the visit by the BBC film crew. She also said staff should direct the crew to take distant video, far enough away so they would not be exposed if the surviving elephants tested positive.

"Please keep things simple," she said, "and explain that our restrictions surrounding visitors and close contact with our elephants are safety precautions that were increased somewhat when the group dynamics changed with the loss of the African elephant."

She suggested in the same e-mail what to say about the loss of Nancy.

"If they or others ask what was wrong with Nancy, the answer should be 'multiple problems, including osteomyelitis and severe arthritis, fairly sudden severe weight loss,' " Spelman wrote, "but we are still waiting for final necropsy results."

In her e-mail, Spelman had added, "If asked a pointed question . . . then of course be truthful. . . . Yes, we are screening the rest of the elephants, yes it can spread to other animals and even people if their immune systems are poor."

Spelman ordered TB tests on the remaining three Asian elephants, which continued to be tested monthly for a year. All results were negative.

The new tests were particularly urgent because the failure to test for TB earlier had allowed an elephant with tuberculosis to be exposed to Shanthi, who after years of attempts had been artificially inseminated and was pregnant with Kandula, now a showcase elephant at the zoo.

Spelman also told staff in an e-mail the day after Nancy was euthanized to "stop behind the scenes tours for now." Such tours conducted for VIPs and donors typically bring people within reach of an elephant's trunk. The Elephant House -- which at the time also held rhinos, hippos and giraffes -- was closed to the general public from September through March. The reason given at the time was "renovations" -- primarily the upgrading of the ventilation system. What was not said was that the system needed upgrades to prevent the spread of infectious diseases, such as TB.

The zoo confirmed the existence of the TB in a news release almost two months later, on Oct. 12.

At the time, Spelman said, "This is not a public health risk." She mentioned the testing on elephants and keepers. She did not reveal that she had taken other precautions, such as closing the Elephant House or restricting behind-the-scenes tours.

Zoo officials said they tried to contact everyone who had close contact with Nancy. But one former employee who spoke on condition of anonymity and visited Nancy within weeks of her death said a call from a Post reporter this year was the first notification she had received that Nancy had TB.

Attempting to reach potentially dozens of other people who took behind-the-scenes tours was considered virtually impossible because such records were inconsistently kept. Records and interviews show that dozens of tours were conducted, as often weekly, between 1999 and Nancy's death in August 2000.

It is unclear how Nancy contracted TB.

After the elephant's death, Spelman in an e-mail acknowledged problems with enforcement of the zoo's own interaction guidelines, though the National Zoo had been one of the first in the country to write a policy to protect elephants and humans from giving each other TB. "I have felt for some time that we have been a bit too relaxed with elephant visitors and film crews (and I have certainly been 'guilty' of this)," Spelman wrote Sept. 18, 2000. "So we should look at updating guidelines."

Zoo officials said that immediately after that, in October, Spelman resumed her own private tours for special guests, which she called "director-led tours."

On Sept. 30, keepers wrote, "Elephants are to be locked out whenever the public has access to the building until further notice!"

On Jan. 6, 2001, while still restricting public access to the Elephant House, Spelman took President Bill Clinton and five family members, including his two young nephews, into the Elephant House. She never told the group about the TB incident or asked them whether they had any medical conditions that might make them susceptible to disease or pose a risk to the elephants, said Tony Rodham, Clinton's brother-in-law, who was on the tour. The zoo's own guidelines say that behind-the-scenes visitors must be asked such questions.

Ultimately, the TB did not spread, and Spelman said there was no risk to Clinton's group or the public.

Spelman said she relied on Montali for guidance with the Clinton tour and others, saying, "He is known worldwide for his expertise on TB in elephants."

Montali said in an interview last summer that it was his understanding that Spelman's director-led tours were kept at a distance from the elephants. "Nobody just sort of went back there and got close to the elephants," he said. "They were totally under conditions where it would be very unlikely that even if an animal was shedding [TB] that they would be able to contract [TB]." As for the Clinton tour, he said, "There was no touching, no trunk contact."

However, photographs taken at the time show that Clinton and his nephews were close to the elephants. The president's hand appears to be less than a foot from the elephant's trunk. The boys "touched the rugged trunk" of Toni, a pachyderm from Thailand, a White House pool report states.

Montali, shown the photos in an interview, said the group nevertheless probably was not exposed.

"If Clinton got on the elevator or a bus with his nephews, he could have had as much a risk getting TB as he did that day being near our Asian elephants," Montali said. "I think there was virtually no risk whatsoever."

Nancy was infected with Mycobacterium bovis, or bovine TB, rather than Mycobacterium tuberculosis, referred to by scientists as M. tb. Although both come from the same strain, M. tb is now far more common in humans than bovine TB, which was sometimes spread among dairy workers a century ago.

Montali said that bovine TB is rare in Asian elephants and that there is no documented case of a human getting the bovine kind from an elephant. Spelman said no visitor or worker was endangered.

"I believe that we were very, very cautious. There's been no case of a person getting any form of TB, let alone bovine, from an elephant."

Doctors do believe there is strong evidence that circus elephants gave M. tb. to elephant trainers in McHenry County, Ill., in the 1990s, said Phil Zimmerman, a retired state health official who co-authored a medical paper on the episode. That case, which was an impetus in creating the USDA testing policy, led to a $60,000 fine for subsequent violations for animal cruelty.

Spelman acknowledged in one of her e-mails after Nancy's TB was found to be in the bovine form that there was still cause for concern. She wrote that "human health issues are still a concern as well as the health of the rest of the [Elephant House] inhabitants."

M. tb. is believed to have evolved from bovine TB. National Zoo workers tested positive for bovine TB in the 1970s after a black rhinoceros contracted the disease. M. tb is believed to be more contagious to humans than bovine TB, but the USDA elephant regulations make no distinction between the two strains in terms of the requirements for testing. Scientists believe that it is possible for humans to contract bovine TB from elephants.

Other animal exhibitors who have failed to administer TB tests have faced USDA investigations and fines. The test only detects TB when the animal is shedding the organisms, but it is considered the gold standard.

Before this year, the USDA said it erroneously concluded that it could enter the National Zoo for an inspection only when invited. After a congressional hearing in March, attorneys for the USDA and Smithsonian reversed course and decided that USDA inspectors could show up unannounced.

"Since we have no enforcement powers over the National Zoo, there is not much we did in terms of enforcement," said Barbara Kohn, a veterinarian in the USDA's Animal and Plant Health Inspection Service.

The panel investigating zoo deaths for the National Academy of Sciences has asked for records covering Nancy's death. In his letter to the science academy, Nichols, the zoo's second in charge in the pathology department for 12 years, said the TB test could have resulted in Nancy being relieved of her suffering much sooner, either through treatment or euthanasia.

"Didn't Spelman's failure to test this elephant for TB result in needless and prolonged suffering for this animal?" Nichols wrote. "Didn't keeping this elephant alive and untreated pose a health risk for humans (staff and visitors) and the other animals in the Elephant House exposed to this infected elephant?"

The science academy panel's chairman said the review will not hold individuals accountable for mistakes or "be pointing fingers." Instead, the panel is writing "objective information on the way the zoo is managed," said its chairman, R. Michael Roberts, a professor of veterinary medicine at the University of Missouri.

Staff researcher Bobbye Pratt contributed to this report.