Zoo Operates Under Gaps In Oversight
Death of Nancy the Elephant Showed Enforcement Flaws

James V. Grimaldi, Karlyn Barker and D'Vera Cohn
Washington Post Staff Writers
Monday, December 8, 2003

Three years ago, officials at the National Zoo euthanized Nancy, an African elephant suffering from foot problems so painful that the 31/2-ton pachyderm leaned her head on the bars of the enclosure to lighten the weight on her feet.

Then zoo pathologists did a necropsy and found something worse: Nancy's lungs were eaten up by tuberculosis, a contagious respiratory disease that went undiagnosed even though records show she exhibited classic symptoms on and off for two years.

Even worse: The National Zoo had failed for almost two years to conduct annual tuberculosis tests on its elephants, which federal rules required of every zoo and circus in the nation after two circus elephants died of TB in 1996.

The zoo's veterinarians at the time, including the zoo's current director, Lucy H. Spelman, were too busy to do the tests, zoo officials said. "I was completely consumed treating really sick animals, of which Nancy [the] elephant was one," Spelman said in an interview last week.

After Nancy's death in August 2000, zoo officials started testing keepers and other elephants, and took other steps to protect the public from exposure. The zoo told the public that the Elephant House was closed for renovations but did not reveal that its euthanized elephant had TB. By mid-September, Spelman learned that zoo staff had tested negative and that the TB was a form that is less infectious than the kind usually found in humans.

Later that month, when a BBC film crew arranged a visit to the Elephant House, Spelman wrote in an e-mail to staff: "I do not see the need to discuss the [TB] issue with the BBC crew unless asked directly." Instead, she advised, staff should say that safety precautions were taken because "the group dynamics changed with the loss of the African elephant."

In October 2000, the zoo announced the existence of the TB in a news release but said there was no public health risk.

"I don't believe I ever put anybody at risk for getting any form of infectious disease from any of our animals, ever," Spelman said last week.

Nancy's death exposed a weak enforcement regime exacerbated by a regulatory gap at the zoo, a Smithsonian Institution animal park. A nine-month Washington Post review of the circumstances surrounding the death of Nancy and other animals found:

* The U.S. Department of Agriculture regulates zoos and enforces the requirement for annual TB tests. But USDA says it has no power to enforce the Animal Welfare Act at the National Zoo. That is because the zoo is a separate federal entity chartered by Congress.

* The National Zoo's only internal oversight body, the Institutional Animal Care and Use Committee, rarely meets or conducts investigations, contrary to the zoo's own policy and federal regulations. In January 2001, the panel shied away from investigating Spelman's veterinary care, citing the "apparent conflict of interest for the [committee] presented by Dr. Spelman's serving as director while still practicing veterinary" medicine, according to the committee's minutes.

After Spelman became director three years ago, keeper Maria Moyers withdrew an allegation that Spelman took eight days to respond to requests to care for an injured tree kangaroo named Guinness. Any finding of fault would have been referred back to the zoo director, Spelman. "What's the point?" Moyers said in a recent interview. "How can you be objective if the complaint is against you?"

Spelman said the animal-care committee "should have an external member, it should meet regularly, it should be a known entity, and it wasn't. We need to have it. It is important."

* Smithsonian Inspector General Thomas D. Blair, the independent internal watchdog for the institution, has looked into the deaths of at least two zebras and two red pandas at the zoo in the past four years, but some zoo employees said the investigations fizzled with negligible results. A Post review of thousands of pages of zoo records and interviews with current and former zoo employees found that human error has marked the deaths of 23 animals since 1998 and that some veterinary records were changed after the fact.

Blair looked into Spelman's role in cutting the diet of an endangered zebra that died of hypothermia and starvation in February 2000, but the investigation waned after she was made zoo director four months later. Blair, who declined to comment last week, said earlier this year that the allegation was left with the zoo's animal-care committee. But the committee's co-chairman, veterinary pathologist Donald K. Nichols, said that after Spelman became director, committee members became conflicted about investigating their boss.

Nichols, who has served notice that he is leaving the zoo, recently submitted a 48-page letter and records to the National Academy of Sciences, which is investigating zoo deaths. He detailed 21 cases that he says represent "long-standing and on-going incompetence, malfeasance and/or malpractice of veterinary medicine."

"It soon became obvious to me that the zoo's administration was not going to reprimand Spelman for the culpability she had in causing the zebra's death, and the investigation by [Deputy Inspector General Richard C.] Otto dragged on for many months," Nichols wrote to the science academy.

Nichols said: "Otto also reminded me that Spelman was 'hand-picked' by Secretary [Lawrence M.] Small to be the Zoo Director. He then warned me that if I did anything that made Spelman look bad, there undoubtedly would be consequences generated from the Smithsonian's administration that would adversely affect me and my career."

Asked to comment, Otto, who is now retired, said Nichols's concerns were warranted. "Generally, the Smithsonian just doesn't get that, as a public trust, it is obligated, unconditionally, to complete transparency and meaningful accountability," Otto said.

Smithsonian spokeswoman Linda St. Thomas said officials would never retaliate against anyone for speaking publicly about problems with Spelman. She said Otto's comment was incorrect, adding, "It might be that since Otto is no longer at the Smithsonian that he is not up-to-date about what's going on."

The Smithsonian is currently fighting with the D.C. Department of Health over a $650 fine against the zoo for hiring an unlicensed pest-control company to kill rats that had overrun animal enclosures. Two endangered red pandas died in January after the fumigators buried rat poison in their pen. A Health Department attorney said the case was important "to ensure the protection of public health."

An attorney for the Smithsonian told the city in a letter that D.C. regulations do not apply to the zoo because, as a part of the Smithsonian, the zoo has "immunity."

A popular attraction at the zoo since her arrival in 1956, Nancy suffered during the last two years of her life from little appetite, weight loss, lethargy and ventral edema, in which fluid seeps from the bloodstream and collects in the skin of the belly, according to a review of hundreds of pages of veterinary records and zookeeper reports. All are symptoms of TB, a disease treatable in elephants with human antibiotics, according to published veterinary literature.

Nancy also was having difficulty walking, a common ailment among captive elephants forced to tread on hard concrete instead of the softer soil of their native habitat.

In January 1999, Spelman decided to treat Nancy's lameness with prednisone, a steroid that is an anti-inflammatory drug and also suppresses the immune system.

In February 1999, Spelman conducted an ultrasound to check on the edema and other problems. She wrote that Nancy might have one of several problems. "Tuberculosis or other granulomatous disease can not be ruled out," Spelman wrote.

Spelman then ordered biweekly tests on the elephant's blood and urine but did not ask for a TB test.

In May 1999, Spelman noted that the prednisone she had ordered for Nancy's foot put her "at risk for secondary bacterial infections."

In July 1999, Nancy was found to have a bone infection called osteomyelitis in her left forefoot, which was treated with antibiotics.

In March 2000, the zookeepers practiced giving Nancy a TB test, going through the motions by placing a few cups of saline water in her nostrils and then getting her to blow into a bag, which would produce a sample that could be cultured. But no actual test was conducted, and no sample from Nancy was ever cultured.

The same day as one of the practice tests, keepers wrote that they were puzzled by the buildup of fluids in Nancy's belly. Still, veterinarians didn't take a sample for culturing.

While Nancy's TB went undetected, Spelman gave interviews to the national media in 1999 and 2000 about geriatric zoo animals and specifically the treatment of Nancy's foot problems. The media focused on Spelman's idea of injecting antibiotics into the foot and applying a tourniquet to concentrate the dose, a technique learned from horse doctors. Spelman and another zoo veterinarian presented two academic papers on the innovation after Nancy died and the TB had been found. Neither paper mentions that the elephant had an undiagnosed case of TB.

Despite Spelman's orders to boost Nancy's diet, the elephant was still lethargic and rejecting her food. By August 2000, Nancy weighed 7,700 pounds, down from 10,000 pounds in 1998.

She was obviously in great pain. She had developed pressure sores on her skin from leaning against walls to take the weight off her sore feet as she slept at night. She had lain down for a few hours one day -- abnormal elephant behavior. "She was resting her head on the bars of the stall," veterinary records on Aug. 19 state. "She does not look very good." Keepers offered treats, but "she does not eat them."

The veterinarians later told pathologists that they had determined that Nancy's pain was "presumably due to degenerative joint disease," according to the pathology report.

She was euthanized Aug. 22 at age 46. Elephants in captivity normally live 50 to 70 years.

The keeper notes end with the entry, "Sad day."

"We did everything we could to treat all of Nancy's symptoms," Marie Galloway, the lead elephant keeper, said recently. She began to cry. "When we could no longer say her quality of life was good, we gave her the gift of peace."

The necropsy, performed the day the elephant died by Nichols and Richard J. Montali, the zoo's chief pathologist, contained a surprise. The bone disease was "moderate," the report states. "The most significant finding," the report says, was "an extensive granulomatous pneumonia involving 60 percent" of the lungs -- tuberculosis that developed one to two years earlier.

The results were unsettling. Among vets who work with captive elephants, TB had become one of the most prominent veterinary issues in the past several years. Yet Nancy had not been tested in 22 months, since October 1998.

The lack of testing has never before been made public. If it had, it would have been especially embarrassing for the National Zoo because one of its own, Montali, had been instrumental in developing the test and persuading the USDA in 1997 to require it annually. "Elephants with tuberculosis can transmit the disease to other elephants, other animals and, potentially, to humans," a USDA policy announcement said.

Zoos and circuses that do not perform the tests can be cited for failing to provide adequate care under the Animal Welfare Act.

National Zoo officials said the tests were not done because the veterinarians were busy with a number of "unusual" circumstances, including the deteriorating health of giant panda Hsing Hsing.

"During the winter of 2000, plans were made to do trunk washes, but they were not carried out," zoo officials said in a written response to questions earlier this year. "The veterinary staff's priority at the time was Nancy's critical foot infection as well as the rest of the collection, including the ailing Hsing Hsing."

Hsing Hsing was euthanized in November 1999, nine months before Nancy.

"We were all very, very busy," said Galloway, the elephant keeper.

Specialists in zoo medicine and elephant care said they would have expected the widely regarded National Zoo to be at the forefront of conducting these state-of-the-art TB tests.

"That kind of surprises me," said Mike Keele, chairman of the species survival plan for Asian elephants and deputy director of the Oregon Zoo in Portland.

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.