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Infection: The Global Threat

The Coming Plague: Newly Emerging Diseases in a World Out of Balance

by Laurie Garrett
Farrar, Straus and Giroux, 750 pp., $25.00

The Hot Zone

by Richard Preston
Random House, 300 pp., $23.00

If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicators of mass disturbances in mass life.”

—Rudolph Virchow

1.

Begin with a thought experiment: What might it take to produce a virus with the potential to eliminate Homo sapiens? For a start, it should be one that we are unfamiliar with; our physical naiveté insures only perfunctory resistance to virulent infection. To preserve the element of surprise, the virus must cross to humans from another species. Airborne transmission would encourage such a leap: a cough or simply sharing a breath, especially if only a tiny amount of virus were needed to establish a human foothold. Once inside us, the virus must multiply with extraordinary rapidity, producing catastrophic and irreversible damage to all major organs: liver, heart, lungs, brain, kidneys, and gut. During this phase of fertile proliferation, subtle but significant changes to its structure (mutation) would enable the virus to evade any rear-guard attempt by our immune system to reestablish control. To give the virus the ultimate upper hand, we should possess neither drug nor vaccine to challenge the infection. Finally, we should be denied the means to restrain viral spread, an easy condition to fulfill if one is ignorant of where it normally (and peacefully) resides.1

If this wish list of virulence sounds improbable, Richard Preston will quickly extinguish your skepticism. With almost unseemly relish, he describes the dramatic emergence from Africa of two viruses—Marburg and Ebola—that fit our “perfect” virus rather too well. For instance,

Ebola…triggers a creeping, spotty necrosis that spreads through all the internal organs. The liver bulges up and turns yellow, begins to liquefy, and then it cracks apart…. The kidneys become jammed with blood clots and dead cells, and cease functioning. As the kidneys fail, the blood becomes toxic with urine. The spleen turns into a single huge, hard blood clot the size of a baseball. The intestines may fill up completely with blood. The lining of the gut dies and sloughs off into the bowels and is defecated along with large amounts of blood.

The strain of Ebola found in Sudan, and first discovered in 1976, is twice as lethal as Marburg, killing half of those it infects. The Zaire strain of Ebola is nearly twice as lethal as its Sudanese counterpart. In The Coming Plague Laurie Garrett recounts the details of these discoveries. In the Yambuku Mission Hospital in northern Zaire, Belgian nuns gave out injections of antimalarial drugs with unsterilized needles. Thirteen days after Mabola Lokela, a schoolteacher recently returned from vacation, received such an injection, he became the first known fatality from Ebola Zaire. Eighteen members of his family and friends perished soon after. The virus proceeded to spread through the hospital and surrounding villages. Thirtyeight of the Yambuku staff died, including all of the missionary nurses. A single needle at Yambuku had magnified this chance tragedy into a devastating epidemic.

The first Western physician to be notified of this public health emergency by Zaire’s Minister of Health was Dr. William Close (whose daughter is the actress Glenn Close). He immediately informed the US Centers for Disease Control (CDC) in Atlanta. Samples of blood and tissue from the Ebola victims were distributed to laboratories throughout the world for analysis. At the University of Anvers in Antwerp, a youthful Peter Piot (who was recently appointed director of the new and streamlined United Nations Program on HIV/AIDS2 ) and his colleagues had discovered an unknown virus in the Yambuku samples. With not unnoticed irony, the microscopic image of the virus assumed the appearance of a “?”.

A small team of virologists, including Piot, was sent to Zaire to investigate. They found that villagers had soon recognized the highly contagious nature of Ebola. Families had been quarantined, the dead had been buried far away from villages, and strict roadblocks had been placed between settlements. The international team of scientists visited 34,000 families in more than 500 villages. Of 358 confirmed episodes of infection, there were 325 deaths. Yet despite intense study, the origin of Ebola remained a mystery. Where was it hiding? Most likely in a nonhuman host, perhaps a spider, a bat, or a monkey. But as a World Health Organization report later noted, “As in the case of Marburg virus, the source of Ebola virus is completely unknown beyond the simple fact that it is African in origin.”

Certainly these events were alarming, but they were also remote. To most people living in the northern hemisphere, the risks that these new viruses posed seemed distant. But an unknown strain of Ebola turned up in Reston, Virginia, a few miles outside Washington, DC, in 1989. One hundred crab-eating monkeys had arrived at the Reston Primate Quarantine Unit from the coastal forests of the Philippines on October 4. Two monkeys were dead on arrival and a further score died during the next few days. Such evidence of the unpredictable and far-flung meanderings of Ebola caused panic.

The laboratory’s veterinarian suspected a common monkey virus, but soon, and contrary to all expectations, the illness spread to the unit’s non-Philippine monkeys. Samples of monkey tissue were sent at once to the US Army Medical Research Institute of Infectious Diseases for examination. When Thomas Geisbert looked into his microscope, he saw the tell-tale “?”-like virus. To the horror of the American team, their tests proved positive for Ebola Zaire. The investigation at Reston quickly moved from an intriguing diagnostic treasure hunt to a potentially volatile political crisis. The quarantine unit was a hot zone containing an organism classified as “biosafety level four”: one for which neither cure nor vaccine existed. Ebola Zaire was now only a few yards away from the Beltway. While the military was being alerted, more Reston monkeys were dying far away from the Philippine shipment, strongly suggesting airborne spread. The biocontainment mission began.3

At this point one might wonder what the press was doing while these events were taking place. The genuine sense of panic and anxiety that surrounded Reston is difficult to convey even after the passage of only a few years. Yet while dozens of monkeys were being slaughtered for safety, most military scientists believed that they were dealing with the world’s most dangerous virus, Ebola Zaire. What was their response, given that these infected animals had been in the US for almost eight weeks? Were nearby residents evacuated? No. Was a surveillance center opened to catch early cases of infection? No.

Instead, the military instituted a planned policy of disinformation, even though two men had already been taken ill, diagnosis unknown. One man was thought likely to have Ebola infection. He was taken to a local community hospital. By complete contrast with the Zaire government’s policy of openhanded collaboration, the American response was to mislead. To stave off unwanted attention from the mass media, children were allowed to play freely around the Reston unit; press inquiries were complacently deflected; and local communities and hospitals were recklessly exposed to danger by medical authorities, who were portrayed as heroic when the story of the virus was finally released.

By a stroke of unbelievable and unexpected good fortune, the Reston strain of Ebola only affected monkeys. Four of the animal workers in the quarantine unit developed symptoms of viral infection, and three could have acquired the virus only through the air. If that virus had proven to be Ebola Zaire, the consequences for Reston—and Washington, DC—are unimaginable.

Richard Preston and Laurie Garrett have both collected an impressive amount of evidence proving the global importance of newly emerging infections, of which Ebola and Marburg are, perhaps, the most dramatic instances. Preston adopts a narrative style of reportage which does not sacrifice scientific accuracy. His tale began as an article published in The New Yorker in 1992, and it benefits from expansion. By rooting the events of Reston in the lives of its central characters, Preston is able to convey the startling fears and uncertainties that these scientists felt as the crisis unfolded. He succeeds in translating the sober facts of research literature, which usually provide post hoc rationalizations and justifications for often hazardous decision-making, into a perceptive account of an emergency.

In describing the discovery of Marburg he has much to say about the lives (and deaths) of two victims who were infected by the virus in 1980 and 1987. Remarkably, a careful exploration of their histories suggested that both might have been infected in a single cave near Mount Elgon on the Uganda-Kenya border. Such odd events wrap further layers of mystery around the origin of these novel viruses. Garrett applies a more conventional, though no less persuasive, journalistic method to her subject, explaining step by step the discovery and evolution of particular viral and bacterial diseases, and considering the various possible ways of controlling them.

Still, in their praise of the physicians and scientists who work on these infections, Preston and Garrett ignore one striking truth: that the single occasion of a potentially species-threatening event in the US produced a disquieting response which exposed remarkable passivity and arrogance among the American research community. Little has happened since to suggest that this same mistake would not be repeated. The rule that secrecy equals safety still holds in the government’s public health service.

2.

The increasingly vociferous message about infectious disease is one of impending apocalypse. Here Garrett brilliantly develops her theme that rapidly increasing dangers are being ignored. Her investigations have taken over a decade to complete, and her findings are meticulously discussed and distilled. Her book is a manifesto for those who see our biological future from a somewhat pessimistic perspective. According to Garrett,

While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators and they will be victorious if we…do not learn how to live in a rational global village that affords the microbes few opportunities.

But what, one might ask, of cataclysmic epidemics of the past? If the ancient Athenians had understood the meaning of microbes, I suspect that they would have shared Garrett’s gloomy view. In 430 BC, Thucydides wrote,

Those with naturally strong constitutions were no better able than the weak to resist the disease, which carried away all alike, even those who were treated and dieted with the greatest care. The most terrible thing of all was the despair into which people fell when they realized that they had caught the plague; for they would immediately adopt an attitude of utter hopelessness, and, by giving in in this way, would lose their powers of resistance. Terrible, too, was the sight of people dying like sheep through having caught the disease as a result of nursing others. This indeed caused more deaths than anything else.4

The Plague of Athens originated in Ethiopia and spread rapidly to Greece. Victims were overtaken with violent fever and declined toward death within a week. By the end of the fourth year of plague, one quarter of the population had perished. The cause of the plague remains a matter of speculation, with smallpox, measles, and typhus the leading candidates. Its origin in central Africa—indeed, in the country neighboring Sudan—raises the additional possibility of a Marburg- or Ebola-like agent. The unusual velocity of physical disintegration, together with symptoms and mortality rates not dissimilar to those of Marburg, adds weight to this possibility.

  1. 1

    See Paul W. Ewald, “The Evolution of Virulence,” Scientific American (April 1993), pp. 86–93.

  2. 2

    The latest initiative on the global AIDS pandemic has merged six United Nations AIDS organizations into one: the Global Program on AIDS, World Bank, UNICEF, UN Development Program, UNESCO, and the UN Population Fund.

  3. 3

    See P.B. Jahrling et al, “Preliminary report: isolation of Ebola virus from monkeys imported to USA,” The Lancet (March 3, 1990), pp. 502–505.

  4. 4

    See Thucydides, History of the Peloponnesian War (Penguin, 1954; revised edition, 1972), Book II, Chapter 51.

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