Crisis in the Red Zone

by Richard Preston

  Pardis Sabeti spends her life studying how viruses evolve and change. For years, she has been telling her Harvard and Broad Institute colleagues that they should keep a month’s supply of preserved food and basic medical supplies in their apartments or homes. A simple precaution, just in case of a Level 4 event. Just in case you might have to practice reverse quarantine for about a month, the same way African villagers do. Cut yourself off from the outside world for a time. “I want to set up the possibility that you might have to stay indoors for a while,” she says to her staff.

  “If we did some basic preparation for a major outbreak,” Sabeti said recently, “we could actually make it not such a huge, dramatic, crazy thing.” Sabeti refers to a Level 4 pandemic as a bananas event. “Why should we be waiting for something that’s truly bananas to break out before we start planning for it?” she asked. “There’s not a lot of value in preparing for a war, because what happens in a war is unpredictable. But there is a lot of value in preparing for an outbreak, because what happens in an outbreak is predictable. Let’s be prepared, not scared.”

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  There is one more story to tell about Kenema, terrible and biblical in its simplicity. In the summer of 2017, Pardis Sabeti and Robert Garry delivered a genome sequencing laboratory to the Lassa research program at Kenema Government Hospital, and the local staff was trained in genome sequencing. During 2018 and 2019, Sierra Leonian technicians sequenced the exact Ebolas that had been in the blood of Kenema Ebola patients. In other words, they revealed the genetic code of the virus swarm that murdered their friends and medical colleagues. The code didn’t lie. It revealed an invisible history, shocking and deeply moving.

  Most observers assumed that the Kenema nurses caught the virus from patients or from people in the local community. The letters of the code told a different truth. The Kenema staff caught the virus from one another as they tried to save one another’s lives. A catastrophic chain of infections among the staff began from a small event. On or about June 30, 2014, ambulance driver Sahr Nyokor decided to break a rule. He didn’t want to embarrass himself or frighten people by wearing a moon suit when he visited some friends in their house. He wore no protection when he entered the house. Somebody inside the house was sick with the Makona strain. That person was closely connected to the funeral of Menindor. The hot Makona jumped from that person into Mr. Nyokor. He threw up blood and went to the hospital. At around six o’clock in the morning on June 18, Mr. Nyokor fell in the toilet and cut his scalp. Nurse Lucy May washed the blood from his cut—a gentle act of care—and he died soon afterward. A few particles of Mr. Nyokor’s hot Makona got into Lucy, likely when she cleaned his scalp, and began explosive amplification in her fetus and herself.

  The Makona strain jumped out of Lucy May into her caregivers on the night of July 3 while she died giving birth to a stillborn child. The code didn’t lie: Auntie Mbalu Fonnie caught the virus from Lucy May as she desperately tried to save Lucy’s life while performing an abortion of the dead baby. The three nurses, Princess Gborie, Sia Mabay, and Fatima Kamara, all caught the virus from Lucy May, most likely on that same night while they, too, tried to save Lucy’s life. Nurse Alex Moigboi also caught Lucy May’s virus while he gave her tender care during the night shifts. It seems pretty clear that Auntie knew she could die if she attempted to save Lucy May. The nurses knew it, too. Auntie and her nurses made the ultimate sacrifice as they attempted to rescue Lucy May; they were like the firemen who ran into the World Trade Center moments before the tower collapsed. They did their duty because it was what they had to do. All of them caught Ebola from Lucy May as they attempted and failed to rescue her from death. Sia Mabay and Fatima Kamara survived their ordeals; Princess Gborie perished along with Auntie.

  Lucy May’s Makona strain expanded out of Auntie. Her brother, Mohamed Yillah, caught Lucy May’s virus from his sister as he tried to save her life.

  And what about Humarr Khan? The letters of the code showed that he, too, was consumed by the fire that started when the ambulance driver went into somebody’s house. The code shows that Khan died of Lucy May’s virus. Wherever and however Dr. Khan caught Lucy May’s virus, he was infected while he was giving care to his own staff. The code shows that Khan did not fail his people, he died with them.

  The virus, a true monster, followed the bonds of fealty and love that joined the hospital’s caregivers to one another and ultimately to every other person on earth. The African medical professionals gave their lives trying to rescue one another, and, at the same time, they served as a thin, dissolving line of sacrifice in which they stood between the virus and you and me.

  EPILOGUE

  A Level 4 Event

  The past is unpredictable. When I first started researching this book, right at the time Humarr Khan died, I had no idea what I would find or where the story would go. I have done my level best to make this narrative accurate and faithful to the strange twists and turns of reality, a bricolage of events, as time goes by. In my view, no work of invented fiction can quite approximate a sense of random coincidence that feels simultaneously like fate. Now, as the past moves into the future, I propose to look ahead. There is a caveat: I may not be any better at prophecy than Wahab the Visioner, although he did make at least one good call. What I propose to look at is a global outbreak that might be termed a Level 4 event worldwide outbreak of a Biosafety Level 4 emerging virus that travels in the air from person to person, and is vaccineless and untreatable with modern medicine.

  The Ebola epidemic seems to be part of a pattern rather than something unusual or extreme. When looked at closely, it was really just a series of small accidents and unnoticed events, which, moment by moment, grew into a crescendo of horror. This was the shockwave produced by an emerging virus as it came out of the ecosystem. The virus magnified itself in people, swept away lives, met opposition from the human species, and finally died out. What will the next shockwave be like?

  As far as anyone knows, Ebola doesn’t travel through the air from person to person. Ebola is a wet virus, and it spreads through contact with liquids or in invisible liquid droplets that can drift a few feet through the air. The question often asked is whether Ebola could evolve to spread through the air in dried particles, entering the body along a pathway into the lungs. Eric Lander, the head of the Broad Institute, thinks that this is the wrong question to ask. Lander is tall, with a square face and a mustache, and he speaks rapidly and with conviction. “That’s like asking the question, Can zebras become airborne?” he said. In order to become fully airborne, Ebola virus particles would need to be able to survive in a dehydrated state on tiny dust motes that remain suspended in the air and then be able to penetrate cells in the lining of the lungs. Lander thinks that Ebola is very unlikely to develop these abilities. “That would be like saying that a virus that has evolved to have a certain lifestyle, spreading through direct contact, can evolve all of a sudden to have a totally different lifestyle, spreading in dried form through the air. A better question would be ‘Can zebras learn to run faster?’ ” There are many ways by which Ebola could become more contagious even without becoming airborne, Lander said. For example, it could become less virulent in humans, causing a milder disease and killing maybe 20 percent of its victims instead of 50 percent. This could leave more of them sick rather than dead, and perhaps sick for longer. That might be good for Ebola, since the host would live longer and could start even more chains of infection. But Ebola will probably always be a wet virus.

  As this is being written, Ebola has become another shockwave, this time in eastern Democratic Republic of the Congo, where hundreds have died of Ebola and the virus is out of control. Nobody knows if or how Ebola might mutate as it chains through human bodies in the current outbreak. But let us suppose that Ebola never evolves into a more serious problem than it is right now. Instead, let us consider a dry virus. Dry viruses have the ability to survive whe
n their particles have no moisture in them. The particles, stuck to dust motes or in microscopic dry flakes of saliva, can drift in the air for long distances.

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  A family of viruses called the morbilliviruses is regarded by some experts as a leading candidate for the emergence of a previously unknown Level 4 monster that travels in the air. If there was no vaccine or drug for it, and if it was highly infectious, and if it floated out of peoples mouths, the virus could go around the world in a few weeks, traveling inside people who are flying on airplanes and walking through airport terminals, breathing. Consider a certain morbillivirus, Nipah, a Level 4 emerger that gets into the lungs and central nervous system, and causes personality changes and liquefaction of the brain. Nipah occasionally breaks out in southeast Asia. It jumps from bats, to animals, to humans—it is a promiscuous virus. Nipah isn’t very contagious right now, but viruses evolve in response to people. And there are other Nipah-like viruses circulating in living creatures in the world’s ecosystems. If a brain-destroying virus was going around like the flu, every person’s risk factor for catching the virus would be breathing. If you live in a city teeming with humans, you are nothing more than a host.

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  Mapp Biopharmaceutical has now created an antibody superdrug for Ebola called the Pan-Ebolavirus Cocktail. This new drug is effective against all species of Ebola virus. As this is being written, the U.S. government is preparing to issue funding to manufacture a huge supply of Pan-Ebolavirus Cocktail to be stored in the Strategic National Stockpile, a secret facility or facilities for mass storage of drugs and vaccines to protect the population against biological weapons and emerging viruses. There is also a new antibody drug for Nipah virus. The Pan-Ebolavirus Cocktail and the Nipah Cocktail are models for drugs of the future—antibody drugs that might be developed quickly in a global emergency and that can be surge-manufactured fast, in large quantities. This is the future. And yet right now we are not prepared.

  A recent study done at the Johns Hopkins University School of Public Health revealed that in all the hospitals in the United States there are only a total of 142 biocontainment red zone beds for patients with a hemorrhagic fever virus such as Ebola. And there are not more than 400 red zone beds for patients infected with an airborne hot virus. So there are a total of 542 hospital beds available in the United States in case of a Level 4 event. And there is a big question whether there are even enough trained nurses and doctors to care for the patients in those 542 red zone beds.

  A question has to be asked: If a Level 4 emerging virus spread to a million people in North America, or in any continent, would hospitals be able to handle the patients and give them care? Would epidemiologists be able to trace and break the chains of transmission if a million people were infected?

  As I think about the supercities of the earth, an image comes to my mind of a field of storage tanks full of fuel. All the tanks are connected by pipes carrying fuel, and the valves in the pipes cannot be closed off completely. If one tank goes up in flames, the entire field of tanks can blow. What the future may hold for the human species in its relationship with the virosphere is in the realm of human choice and the play of chance. Wahab the Visioner believed that we can change our fate if we can see it coming, and that human actions can sometimes, not always, change a pattern of events as they jiggle and bump their way into the future.

  By now, the warriors who stand watch at the gates of the virosphere understand that they face a long struggle against formidable enemies. Many of their weapons will fail, but some will begin to work. The human species carries certain advantages in this fight and has things going for it that viruses do not. These include self-awareness, the ability to work in teams, and the willingness to sacrifice, traits that have served us well during our expansion into our environment.

  If viruses can change, we can change, too.

  GLOSSARY

  amplification Strong multiplication of a virus, leading to a large increase in the number of virus particles. See also replication.

  Biosafety Level 4 Also BSL-4 or Level 4. Highest level of biocontainment; requires the wearing of a bioprotective space suit.

  biocontainment The methods and technology for containing a hazardous biological agent and preventing it from infecting people.

  biosphere The totality of the global ecological system of all living organisms. See also virosphere.

  cadaveric blood Blood from a corpse.

  chain of transmission The movement of an infectious agent going from person to person.

  cross-species jump of a virus The process whereby a virus changes the type of host it infects, jumping from one kind of host to a different kind of host.

  electron microscope A powerful microscope that uses a beam of electrons to make an image of something very small.

  emerging virus “Viruses that have recently increased their incidence [in humans] and appear likely to continue increasing.” Term and definition coined by virologist Stephen S. Morse. Many emerging viruses exist naturally in animal hosts and make cross-species jumps into humans.

  epidemiology The science and art of tracing the origin and spread of diseases in populations, with the goal of controlling or stopping the diseases.

  filovirus Family of viruses that are genetically related and all have a similar threadlike or stringlike shape.

  genome “The complete set of genes or genetic material present in a cell or organism.” (Oxford Dictionaries.)

  host An organism that a parasite lives in or on.

  hot agent A Biosafety Level 4 virus.

  hot Virulent (causing severe disease) and highly infectious.

  mutation A change in the “spelling” of the genetic code of an organism, which can sometimes result in a change in the biology and character of the organism.

  parasite An organism that lives inside or on a host organism and harms the host or does it no good.

  pathogen A disease-causing microbe or virus.

  PCR machine A machine that uses the polymerase chain reaction to detect genetic code in a sample such as a blood sample.

  PPE Personal protection equipment. Nonpressurized bioprotective PPE typically consists of an impermeable suit that covers the whole body from head to feet, eye protection, a high-efficiency breathing mask, protective gloves, and rubber boots.

  red zone Extreme biocontainment ward for designed for isoation of patients infected with a highly dangerous virus.

  replication Self-copying. See also amplification.

  virosphere The totality of the system of viruses in the world of living nature. See also biosphere.

  virus Very small replicating life form, and parasite, consisting of a capsule made of proteins which contains DNA or RNA, which is the virus’s genetic code. A virus is only able to replicate inside cells of a host.

  Dedicated to the brave women and men who risked or lost their lives to Ebola as they worked at Kenema Government Hospital protecting their nation and the world.

  ACKNOWLEDGMENTS

  Many people provided important assistance for the making of this book. I am eternally grateful to them, because without their kind help the book wouldn’t exist. If I’ve left out someone’s name in the following list, the omission is inadvertent, and I do apologize for it. Any errors of fact in this book are mine alone.

  Kenema Government Hospital

  First and foremost, I wish to thank the staff of Kenema Government Hospital for their generous help in sharing with me their recollections, thoughts, and perceptions, as well as for their unfailing kindness to me, a visitor. I can only hope to use my best words to do some sort of justice to their courageous and dedicated service in medicine and public health. I wish to specially thank Francis Baimba, James Bangura, Gabriel Bundu-Kainessie, Mohamed Fomgbeh, Michael Aiah Gbakie, Augustine Goba, Dr. Abdul
Azziz Jalloh, Simbirie Jalloh, Fatima Kamara, Lansana Kanneh, Veronica Jattu Koroma CN, James Koninga, Mambu Mohmoh, Doris Moriba, Joseph Henry Moseray, Isaac Tucker Musa, Ibrahim Saffa Ngobah, John Sesay, Mohamed Sow, Dr. Mohamed A. Vandi, and Mohamed Sankoh Yillah.

  Tulane University