That ought to buff right out.
Posted on 10/25/2014 7:33:01 AM PDT by 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.
Actually, this author’s (Tara something)obsession with a book called “The Hot Zone” aside, I see numerous references and little tidbits about her mature extraordinary epidemiological ability and the like and a dragging, dreary account of the book’s presented symptoms and autopsy description along with some character dislikes.
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?
Dr. Tara .....while I guess you think perceptions are wrong because of some 20 year old book, MY perception is that it is due to a complete incompetency of our government, both in leadership AND in execution by agencies whose VERY NAMES imply they’re supposed to be the experts. My only comment is that if THEY’RE the experts, we are in for some deep kimche
There's not very much to it, other than the graphic and gruesome descriptions of the ultra-virulent viral hemorrhagic fever that is the villain of the story.
I thought (at the time) that it might be somewhat over the top. It did, however, make a lasting impression on me.
The author seemed to be making a conscious attempt to imitate Michael Crichton's The Andromeda Strain in designing and composing The Hot Zone. However, author Richard Preston is definitely not Dr. Crichton's league as a storyteller, or as a medical person. Medical and scientific detail in the story is almost completely lacking.
I thought Mr. Preston had a friend who was a doctor, and had got him to expound - maybe after having plied him with a couple of drinks - on the worst-case scenario for the progress of Marburg or Ebola in an individual. He then wrote this description into the first couple of chapters, personalizing it with a large portion of dramatic license.
After those initial chapters, the story thins out almost to nothing, and is pretty much unreadable.
She lost me when she used to word “mythos” rather than “myths.”
I am of the opinion that the ebola "crises" we are having is probably overblown. What we have, however, is a Crises of Leadership.
So 50 to 90 percent of people who get ebola don’t die?
What I remember from The Coming Plague is that the virus can affect your heart valves (and other muscular organs) thus causing death.
The CDC has done SUCH a bad job at communicating and leading, it amazes me every time I think about it, which is often.
It's been obvious for several months that animal vector contact, corpse handling, and direct physical contact including small inoculum skin contact are how Ebola spreads.
And yet, CDC both stuck to their hospital infection prevention guideline weeks after it was known to be inadequate AND terrified 800 airline passengers who they knew had effectively zero risk, at the same time the third week in October.
The CDC made two critical errors in July, both driven, I believe, by the need to (or orders to) support an open borders ideology.
The first error was their "Any US hospital with a private room can safely care for an Ebola patient" web article. The second was to answer the question of advanced PPE in West Africa by saying, in effect, "Africa is dirty, we don't need to worry about nurses here".
Both of these strong positions were supported by weak or nonexistent evidence, but both needed to be true if expedited visas and free movement for West Africans entering the US were to be implemented.
Now, they own the results, one of which is great, and mostly unnecessary, public fear.
My work involves Ebola preparation and worker protection. I've been studying infections for 40 years. Here's what you need to do:
1) Don't eat fruit bats or other bushmeat.
2) Don't carry corpses through the streets or spray/lavage them.
3) If you need to care for a patient with advanced Ebola, use PPE (after training on it) with no skin showing and a decon spray or shower before you undress.
4) You can safely are for an Ebola patient in the early stages with regular PPE, but ask for, train with, and use advanced PPE if you have the slightest doubt about that.
5) Do not believe people who say Ebola spreads on bowling balls. The negative data for environmental surfaces is very strong.
Yes, and despite the author's attempts to diminish the threat of Ebola, this sentence alone powerfully states the risk. It's not about ‘crossing the room’ in the air. It's about the fact that there are receptors for this virus in enough cell types in the body such that it can be transmitted by a number of potential routes - and is deadly. The physician who contracted Ebola and who is now in Bellevue was wearing high-level protective gear and still contracted it. It's not like HIV, and that is the way the CDC initially tried to characterize it.
Normally I would agree with you, but we're talking in this case about bowling balls in New York City...
From this thread which links to a photojournalist's actual, real world, experience with Ebola in Liberia. From that article:
In Liberia today, it's the things you can't see that are most lethal. One twist of an infected door knob or an accidental brush past a stranger can be your death sentence."
Who to believe...who to believe...
So there you go... Ebola is nothing to worry about. It’s all just a work of fiction. What a relief.
Well, I am glad some bloggers are discussing this.
I think I understand something now, well, at least a little better than I did.
I have explained over and over on this forum how Ebola is not airborne, and won’t ever be airborne, and have received a lot of hostility for saying so. I link to research articles explaining the science of Ebola, and am told that I have no clue what I’m talking about. Yet, among people who frequent this forum, I doubt anyone has the experience working with pathogens that I do. Telling a real scientist that she doesn’t know what she’s talking about (even when she backs up her statements with peer-reviewed research papers) is something like insisting to a pilot that you, the passenger, understand better how planes function than he does.
It’s more than a little exasperating.
People who have read The Hot Zone know nothing about Ebola. Really.
Doctor's Without Borders have protocols that shame the CDC's lame imitations. Yet doctors within that organization - doctors who have treated Ebola in Africa have been infected and often died. That's new to this strain of Ebola.
Nobody who has tried (and some very good people have tried, very recently) to isolate Ebolavirus RNA from environmental surfaces, including hospital surfaces frequently contaminated by other pathogens, have succeeded.
Skin to skin contact with a symptomatic patient? Deadly.
Doorknobs? Does not seem likely, based on real data from very good people.
The reason you are falling back on "people are wrong" is that our government, driven by ideology and PERCEPTION - the OPTICS!, is woefully over matched here with the realities, and your decades of focused training point automatically and understandably to the scientific side of the equation.
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.
Frankly, this government is largely talking out of its ass. It took a Democrat Governor in NY, bi-partisanly backed up by a Republican Governor to start real quarantines to even get a blurb in the media that "Obama now is thinking about quarantines."
So, there IS misperception here on the part of the public, but I submit that the arrogance of this "we got this" government coupled with its incompetence is the real problem.
Doctor's Without Borders have protocols that shame the CDC's lame imitations. Yet doctors within that organization - doctors who have treated Ebola in Africa before in past breakouts - have been infected this time. That's new to this strain of Ebola. Something is different.
Well, that is A problem, all right, and a big one at that.
That ought to buff right out.
No it isn't.
A high (and poorly explained, until now) attack rate among hospital workers, especially doctors and nurses, has been a feature of ebolavirus epidemics since the beginning in 1976.
It is, in fact, one of the reasons we don't know as much about it as we could or should.
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