"The Hot Zone" and the mythos of Ebola

Aetiology ^ | October 21, 2014 | Tara C. Smith

[No One Special]

The Hot Zone was first released in 1994, the year I graduated high school. Like many readers, that book and Laurie Garrett’s The Coming Plague* really sparked my interest in infectious diseases. In some sense, I have those books to thank (or blame?) for my career.

But I’m still going to criticize The Hot Zone, because as a mature infectious disease epidemiologist and a science communicator in the midst of the biggest Ebola outbreak in history, The Hot Zone is now one of the banes of my existence. A recent article noted that the book is back on the bestseller list, going as high as #7 on the New York Times list recently, and #23 on Amazon. It’s sold over 3.5 million copies, and it’s reported as “a terrifying true story.” Many people have gotten almost all of their Ebola education from just The Hot Zone (as they’ve told me over, and over, and over in the comments to this blog and other sites).

Here’s why The Hot Zone is infuriating to so many of us in epidemiology and  infectious diseases.

First–the description of symptoms. Preston himself admits that these were exaggerated. Over and over, he uses words like “dissolving,” “liquefy,” “bleeding out” to describe patient pathology. (If I had been playing a drinking game while reading and did a shot every time Preston uses “liquefy” in the book, I’d be dead right now).

Of a Marburg patient, pseudonymously named Charles Monet, he describes him as

“…holding an airsickness bag over his mouth. He coughs a deep cough and regurgitates something into the bag. The bag swells up….you see that his lips are smeared with something slippery and red, mixed with black specks, as if he has been chewing coffee grounds. His eyes are the color of rubies, and his face is an expressionless mask of bruises. The red spots…have expanded and merged into huge, spontaneous purple shadows; his whole head is turning black-and-blue…The connective tissue of his face is dissolving, and his face appears to hang from the underlying bone, as if the face is detaching itself from the skull…The airsickness bag fills up to the brim with a substance known as the vomito negro, or black vomit. The black vomit is not really black; it is a speckled liquid of two colors, black and red, a stew of tarry granules mixed with fresh red arterial blood. It is hemorrhage, and smells like a slaughterhouse….It is highly infective, lethally hot, a liquid that would scare the daylights out of a military biohazard specialist…The airsickness bag is brimming with black vomit, so Monet closes the bag and rolls up the top. The bag is bulging and softening, threatening to leak, and he hands it to a flight attendant.

“…the body is partly transformed into virus particles…The transformation is not entirely successful, however, and the end result is a great deal of liquefying flesh mixed with virus…The intestinal muscles are beginning to die, and the intestines are starting to go slack…His personality is being wiped away by brain damage…He is becoming an automaton. Tiny spots in his brain are liquefying…Monet has been transformed into a human virus bomb.

“…The human virus bomb explodes…The victim has “crashed and bled out.”…He becomes dizzy and utterly weak, and his spine goes limp and nerveless and he loses all sense of balance….He leans over, head on his knees, and brings up an incredible quantity of blood from his stomach and spills it onto the floor with a gasping groan. He loses consciousness and pitches forward onto the floor. The only sound is a choking in his throat as he continues to vomit while unconscious. Then comes a sound like a bedsheet being torn in half, which is the sound of his bowels opening and venting blood from the anus. The blood is mixed with intestinal lining. He has sloughed his gut. The linings of his intestines have come off and are being expelled along with huge amounts of blood. Monet has crashed and is bleeding out.”

And later, at autopsy:

“His liver…was yellow, and parts of it had liquefied–it looked like the liver of a three-day-old cadaver. It was as if Monet had become a corpse before his death…Everything had gone wrong inside this man, absolutely everything, any one of which could have been fatal: the clotting, the massive hemorrhages, the liver turned into pudding, the intestines full of blood.”

And I didn’t even get to what Preston says about Ebola and testicles. Or pregnant women. Seriously, there’s pages upon pages upon pages of this stuff.

Throughout the book, Preston presents these types of symptoms as typical of Ebola. Not “in worst case, this is what Ebola could do,” but simply, “here’s what happens to you when you get Ebola.” It’s even beyond a worst case scenario, as he notes in part: “In the original ‘Hot Zone,’ I have a description of a nurse weeping tears of blood. That almost certainly didn't happen.”

Compare that to just about any blog post by actual workers with Médecins Sans Frontières, healthcare workers on the front lines of this and many previous Ebola outbreaks. Stories are scary enough when the reality of the virus is exposed, and with it the dual affliction of poverty and the terrible health system conditions of affected countries. I interviewed MSF’s Armand Sprecher a few years back during a different Ebola outbreak, and he noted this about symptoms–quite different from the picture Preston paints:

The patients mostly look sick and weak. If there is blood, it is not a lot, usually in the vomit or diarrhea, occasionally from the gums or nose.

The clinical picture of Ebola that people take away from The Hot Zone just isn’t accurate, and with 3.5 million copies sold, is certainly driving some (much? most?) of the fear about this virus.

Second, airborne Ebola. Though this trope is often traced back to “Outbreak,” Preston clearly suggests that both Zaire Ebolavirus and Reston Ebolavirus can be airborne. What he never discusses nor clarifies is that the “evidence” for this potential airborne spread is really thin, and not even indicative of animal-to-animal or animal-to-person transmission.

Rather, it’s much more likely that if airborne spread was involved, it was aerosols generated by husbandry (such as spraying while cleaning cages), rather than ones which would have been generated by infected primate lungs (a necessary step for primate-to-primate transmission via a respiratory route). Indeed, this is the paper that Nancy Jaax et al. published on the findings Preston talks to Jaax about, 13 years after the fact (the experiment is marked as 1986 in The Hot Zone), and noting that transmission due to husbandry practices could not be completely ruled out. It’s unclear also that the Reston strain moved through the primate facility via air, rather than via spread due to caretakers, equipment, or husbandry. Nevertheless,  it’s frequently cited as fact and without any qualification that Reston is an airborne type of Ebola.

Instead, here is what Preston says about it:

“If a healthy person were placed on the other side of a room from a person who was sick with AIDS, the AIDS virus would not be able to drift across the room through the air and infect the healthy person. But Ebola had drifted across a room. It had moved quickly, decisively, and by an unknown route. Most likely the control monkeys inhaled it into their lungs. ‘It got there somehow,’ Nancy Jaax would say to me as she told me the story some years later. ‘Monkeys spit and throw stuff. An when the caretakers wash the cages down with water hoses, that can create an aerosol of droplets. It probably traveled through the air in aerosolized secretions. That was when I knew that Ebola can travel through the air.'”

He then comes back to “airborne Ebola” several times, based in part on this idea.

But here’s the thing. Just about any virus or bacterium could be aerosolized this way–via high pressure washing of cages, for example. If it can bind to lung cells and replicate there, as we already know Ebola can, it can cause an active infection.

But that’s not the same as saying “Ebola can drift across the room” from one sick person to a healthy person and cause an active infection, as Preston tries to parallel with HIV in the above paragraph. Even in Jaax’s experiment and others like it, there’s zero evidence that primates are expelling Ebola from their lungs in a high enough concentration to actively infect someone else. And that is the key to effective airborne transmission. Think of anthrax–if it’s released into the air, we can inhale it into our lungs. It can replicate and cause a deadly pneumonia. But anthrax isn’t spread person-to-person because we don’t exhale the bacteria–we’re dead ends when we breathe it in. This is what happens with primates as well who are experimentally infected with Ebola in a respiratory route, but Preston implies the opposite.

Third, if it wasn’t for points one and two, The Hot Zone really could be read as a “damn, Ebola really isn’t that dangerous or contagious so I have little to worry about” narrative. Preston describes many “near misses”–people who were exposed to huge amounts of “lethally hot” Ebola-laden body fluids, but never get sick–but doesn’t really bother to expose them as such. All 35 or so people on the little commuter plane Monet flies on between his plantation in western Kenya and Nairobi, deathly ill, vomiting his coffee grounds and dripping nasal blood into the airsickness bag he handed to a flight attendant–none of them come down with the disease.

The single secondary infection Monet causes is in a physician at the hospital where he’s treated, after his bowels “ripped open” like a bedsheet. That physician, Shem Musoke, not only swept out Monet’s mouth until “his hands became greasy with black curd” but also was “showered” with black vomit, striking him in the eyes and mouth. Monet’s blood covered Musoke’s “hands, wrists, and forearms,” because “he was not wearing rubber gloves.” Musoke developed Marburg virus disease, but survived–one of the few secondary cases of infection described in the book.

Another “close call” was that of Nurse Mayinga N. She had been caring for one of the Ebola-infected nuns at Ngaliema Hospital in Kinshasa during the 1976 outbreak in Zaire, the first detected entry of Zaire Ebolavirus into the human population. Beginning to feel ill herself, she ditched her job and disappeared into the city for two days. She took a taxi to a different, larger, hospital in the city, but was sent away with a malaria shot. She’s examined at a third hospital and sent away. Finally she returns to Ngaliema hospital and is admitted, but by that time, had caused a panic. Preston says:

“When the story reached the offices of the World Health Organization in Geneva, the place went into full-scale alert…Nurse Mayinga seemed to be a vector for an explosive chain of lethal transmission in a crowded third-world city with a population of two million people. Officials at WHO began to fear that Nurse Mayinga would become the vector for a world-wide plague. European governments contemplated blocking flights from Kinshasa. The fact that one infected person had wandered around the city for two days when she should have been isolated in a hospital room began to look like a species-threatening event.”

How many secondary cases were the result of Mayinga N’s wanderings? That possibly “species-threatening” event? Preston again devotes several paragraphs to Mayinga’s gruesome illness and death, and notes that 37 people were identified as contacts of hers during her time wandering Kinshasa. He tells us they were quarantined “for a couple of weeks.”

The fact that exactly zero people were infected because of Mayinga’s time in Kinshasa merits half a paragraph, and not dramatic or memorable. “She had shared a bottle of soda pop with someone, and not even that person became ill. The crisis passed.” <–Yes, that is a direct quote and the end of the chapter on Mayinga. Contrast that to Preston’s language above.

Finally, beyond the science and the fear-mongering about Ebola, beyond everything and everyone in the story “liquefying” and “dissolving” and “bleeding out,” reading this book again as an adult, as a woman in a science career with a partner and kids, I was also left annoyed at the portrayal of the scientists. All of the major characters except one, Nancy Jaax, are men of course, ranging in age from late 20s to 50s-60sish. Understandable since this is in a mostly-male military institution and in a BLS4 setting to boot, but the one Preston focuses on for much of the narrative is Jaax.

While Preston may have been trying to portray Jaax as the having-it-all, tough-as-nails woman scientist, the fact that she’s the only one with any kind of home life is telling–mostly because he devotes more paragraphs to how she neglects both her children and her dying father than any success she has in her life outside of work. She is told early on by one of her colonels that “This work is not for a married female. You are either going to neglect your work or neglect your family.” This thought comes up repeatedly for Jaax, and in the end, while she was accepted and even honored by her colleagues and bosses, we hear over and over again how her children are left on their own to microwave meals and tend to their homework. How they desperately wait up for her to get home after work, often eventually falling asleep in her bed before she arrives. How she tells her father, dying of cancer back in Kansas and both knowing he only has a few hours to days to live, good-bye and “I’ll see you at Christmas” over the phone. How she barely arrives on time for his funeral after he passes.

We hear one paragraph about how another colleague, Thomas Geisbert, had a crumbling marriage with two small children, and how he left the children at his parents’ house for a weekend. Other than that, the personal lives of any other characters are practically absent, save for Jerry Jaax, Nancy’s husband. Even with him, much of the character development revolves around his fears of his wife working in a BSL4 lab.

The Hot Zone, for me, is unfortunately one of those books that you read as a young person and think is amazing, only to revisit years later and see it as much more shallow and contrived, the characters one-dimensional and the plot predictable. The problem is that The Hot Zone is not just a young adult novel–it’s still presented and defended as an absolutely true story, especially by huge Preston fans who seem to populate comment threads everywhere. And now it looks like there will be a sequel. At least it should be good for a drinking game.

 

*I’ll note that The Coming Plague is much more measured when it comes to Ebola–the two were grouped together because temporally, they were released close together, not because they display the same type of hype regarding the virus.

[Steely Tom]

However, we were actually hearing "No problem here in the US - wash your hands" for cripes sake. Likewise the first words out of Friedan's mouth on hearing a Dallas Nurse got infected "the protocol was breached." It was only until days later that anyone from government admitted that the 'protocols' need to be rethought.

Obviously he meant "the future protocol was breached."

[Gaffer]

I was an engineer and later an engineering manager over my 35+ year career. One of the “laws” I handed down to any new engineer was that if they were ever asked a question to which they did not have the answer was to NOT talk out of their ass trying to answer the question.

[Tennessean4Bush]

Ok. So the hell what? To me, she prattles on obsessively about this and that minutia and then somehow translates that to peoples’ perception about this crisis being wrong somehow?

I agree that it took a little while for the author to get there, but I think the money quote is the following.

But that’s not the same as saying “Ebola can drift across the room” from one sick person to a healthy person and cause an active infection, as Preston tries to parallel with HIV in the above paragraph. Even in Jaax’s experiment and others like it, there’s zero evidence that primates are expelling Ebola from their lungs in a high enough concentration to actively infect someone else. And that is the key to effective airborne transmission. Think of anthrax–if it’s released into the air, we can inhale it into our lungs. It can replicate and cause a deadly pneumonia. But anthrax isn’t spread person-to-person because we don’t exhale the bacteria–we’re dead ends when we breathe it in. This is what happens with primates as well who are experimentally infected with Ebola in a respiratory route, but Preston implies the opposite.

This is helpful to me. Gives some hope to a scary situation and calms my nerves a bit about the doctor in NYC who bowled and traveled the subway.

Don't get me wrong, I still worry about our government's ineptitude and wonder why they cannot seem to bring themselves to be more rigorous about travel to and from West Africa. But good information like this is helpful, imho.

[Steely Tom]

I'm an engineer.

The people who make up the leadership levels of the Obama administration are definitely not engineers. They don't think like engineers, act like engineers, or talk like engineers.

They talk out of their asses every day of the week.

[DouglasKC]

Skin to skin contact with a symptomatic patient? Deadly. Doorknobs? Does not seem likely, based on real data from very good people.

It's interesting but I've been tracking how Eboloa spreads since early summer. Every couple of days I go onto google and type "How does Ebola spread". Up until about a week ago the top results always said something like you can catch it from objects handled by sick patients.

Now that's changed. In order to avoid panic the new czar has apparently clamped down on this. But it doesn't change reality.

The scary fact is that the Eboloa virus is spread much like the common cold:

How is the common cold transmitted?

The common cold is spread either by direct contact with infected secretions from contaminated surfaces or by inhaling the airborne virus after individuals sneeze or cough. Person-to-person transmission often occurs when an individual who has a cold blows or touches their nose and then touches someone or something else. A healthy individual who then makes direct contact with these secretions can subsequently become infected, often after their contaminated hands make contact with their own eyes, nose, or mouth. A cold virus can live on objects such as pens, books, telephones, computer keyboards, and coffee cups for several hours and can thus be acquired from contact with these objects.

Now sneezing or coughing aren't (they say) symptoms of ebola. But ebola victims still sneeze. And they still cough. And they touch things. A bowling ball being handled by sweaty man WITH ebola isn't something i would be touching any time soon.

[Gaffer]

...But that’s not the same as saying “Ebola can drift across the room” from one sick person to a healthy person and cause an active infection

With all due respect, the very FIRST thing I did when I heard this "wash your hands crap" was to Google "sneezes." I came on a link to a Mythbusters short that shows a video of their investigation into sneezes. The video CLEARLY shows spray going up to 4 or more feet. Which was NOT communicated by Friedan in ANY of his initial statements or interviews.

Amazingly, it took an interview by Sanjay Gupta to, during and interview, ask Friedan the question, "and if someone sneezes?" ONLY THEN did Friedan relate that there was a distance component to being in proximity or close contact with an infected person.

Likewise, one of the first communications out of CDC's or NIH's repertoire upon hearing about Ms Pham being confirmed that it was "low level".....uh....okay. Is that like just a little bit pregnant? Or does that mean it's easier to control and cure if it's caught in time? Does that mean we can let it all fester for a while and still be okay?

My point is that these BUREAUCRATS are bull$hitting us. They have to be dragged to the real answer. Meanwhile, real leaders out in state governments are doing the jobs that the federal government are too cowardly to do because of the Optics and the chance it will make Obama look bad.

[Guenevere]

Bttt

[ClearCase_guy]

One of the prime takeaways should be this -- and it really has nothing to do with Ebola, as such:

The government cannot handle a crisis.

NOTE: I'm not saying Ebola is a crisis. I'm saying that if a terrorist were to introduce a bio-weapon, or if an EMP went off, or if 100 suicide bombers came up through Mexico, or if a dirty radioactive bomb went off, or any of a number of scenarios -- if faced with a crisis, the American government would do two things and two things only:

1) Look at the polls to weigh how the crisis would affect the next election
2) Go on TV and lie.

That's all the government is capable of these days.

[Steely Tom]

You pretty much summed up there.

And the MSM loves it.

Of course, if Ebola gets a hold in their home town NYC, their point of view might change. I emphasize might.

[ansel12]

The novel has been used as THE source for many freepers here, especially in the early months of their hysteria and wild postings.

[ansel12]

I'm not saying Ebola is a crisis. I'm saying that if a terrorist were to introduce a bio-weapon, or if an EMP went off, or if 100 suicide bombers came up through Mexico, or if a dirty radioactive bomb went off, or any of a number of scenarios --

That is what we have learned and need to take from this Ebola situation, after all the billions of dollars, and countless drills, that in the last 50 years the government and institutions and agencies, have all regressed in preparedness over where they probably were in the 1950s.

We need to use this situation to lead to real gains in preparedness for bio terrorism and EMPs, etc.

[Smokin' Joe]

Ping...

A link to this thread has been posted on the Ebola Surveillance Thread

[PA Engineer]

Doorknobs? Does not seem likely, based on real data from very good people.

The survival of filoviruses in liquids, on solid substrates and in a dynamic aerosol

These low infectious dose reports suggest that if the initial viral titre is high, infectious quantities of viable virus could be recovered from samples stored at +4°C for periods of up to 46 days in liquid media, and from samples dried onto glass at both 26 and 50 days.

[mom of young patriots]

Yup. Not analytical, not methodical, not logical, not even rational, just political. And worst of all, not honest. No one will believe what they can’t trust.

[Jim Noble]

It is of some interest that both Pham and Vinson appear to have had milder illness than the evacuees from Liberia.

We’ll have to wait to hear from the NIH and Emory units - but it IS interesting.

[MD Expat in PA]

FWIW

That first picture is not that of an Ebola victim but of the suicide bomber (Boko Haram) responsible for the April 2014 blast at a UN office in Abuja, Nigeria. You can still see what is left of his suicide bomb vest.

http://celebgistz.info/?p=1547

The third picture is also not of an Ebola victim but from someone with Leukemia cutis and the original image is taken from a medical journal in India.

http://www.ijdvl.com/article.asp?issn=0378-6323;year=2010;volume=76;issue=6;spage=710;epage=712;aulast=Misri

http://en.wikipedia.org/wiki/Leukemia_cutis

The second picture? Not sure what that is since I can’t find any original source for the image, but keep in mind that I’ve seen the other two pictures posted here and on other sites and FB pages and blog posts claiming them to be of Ebola victims along with this picture which is not of that of someone with Ebola but of someone suffering from Small Pox.

[Gaffer]

That’s a good thing if there is some dilution that doesn’t grow quickly. Maybe you can be “just a little bit pregnant” then.

[generally]

I don’t believe anything until it’s been officially denied by the 0vomit administration.

[Alamo-Girl]

Thanks for the ping!