Crisis in the Red Zone: The Story of the Deadliest Ebola Outbreak in History, and of the Outbreaks to Come

by Richard Preston

One way to understand viruses is to think about them as biological machines. A virus is a wet nanomachine, a tiny, complicated, slightly fuzzy mechanism, which is rubbery, flexible, wobbly, and often a little bit imprecise in its operation—a microscopic nugget of squishy parts. Viruses are subtle, logical, tricky, reactive, devious, opportunistic. They are constantly evolving, their forms steadily changing as time passes. Like all kinds of life, viruses possess a relentless drive to reproduce themselves so that they can persist through time.

Ebola is one of a class of pathogens known as emerging viruses. An emerging virus, typically, is one that naturally infects some species of wild animal but is also capable of infecting humans. The virus can jump from its wild host into a person and can begin replicating in the person. This is a process known as the cross-species jump of a virus.

Nobody knew then, nor does anybody know now, where emerging viruses are going or what one of them might become. The human host has been gathering itself into gigantic supercities, teeming urban megahives packed with tens of millions of individuals jammed into a small space, who are breathing one another’s air and touching one another’s bodies. The supercities are growing larger all the time. Many of the world’s largest supercities are crowded with people who have little or no access to doctors and medical care. The cities are connected by airline routes, and the human host has zero immunity to any emerging virus.

Everything that lives gets infected with viruses. As far as anyone knows, viruses replicate in the cells of all species of living things, all of them, from bacteria to blue whales.

At the funeral of Menindor, as people expressed their grief and touched Menindor and touched one another, some of the particles that had once coated her bare skin were transferred from person to person until the crowd got smeared with Ebola. People got particles on their fingers and hands, on their faces, in their hair and clothing, and in their eyes. Ebola virus moves from one person to the next by following the deepest and most personal ties of love, care, and duty that join people to one another and most clearly define us as human. The virus exploits the best parts of human nature as a means of travel from one person to the next. In this sense the virus is a true monster.

He could now see the problem only too clearly: The local people didn’t believe that Ebola was real. The virus was out there, it was spreading, and the local people would become violent if the team tried to find it. It was very clear to him—after nearly being killed in a village—that his nation was heading for a disaster. All he could do, personally, was just keep working and try to keep his family safe.

The worldwide eradication of smallpox, led by a small team of doctors at the World Health Organization, and accomplished by tens of thousands of vaccinators, is the greatest achievement in the history of medicine.

This survivor blood had antibodies to the X virus in it. This meant the blood would react to the X virus. But it wouldn’t react to other viruses. That afternoon, Patricia Webb, working with a colleague named Jim Lange, discovered that the survivor blood didn’t react to any known viruses. Therefore the blood had been infected with an unknown virus. And therefore the virus was new to science. Two weeks later the virus would be named Ebola. Patricia A. Webb is credited as the principal discoverer of Ebola virus, along with Karl M. Johnson, Frederick A. Murphy, and James V. Lange.

Josiane wasn’t quite as relaxed as her husband was about the virus. As she explained to him, what worried her wasn’t the virus itself. No, it was the Americans. She was Belgian, and she had a certain view of Americans. A positive view of them on the whole. Now it wasn’t that they were bad people, it was just that they were Americans. And this was a problem. Because, as everyone knew, Americans did not typically know what they were doing. She had begun to imagine that the Americans could do something idiotic with the virus and Jean-François could end up getting infected.

An Ebola treatment center of Doctors Without Borders is the Ancient Rule updated with plastic. A hut made of palm fronds, placed apart from the village and stocked with water and food, was an ancient red zone. Smallpox victims were isolated in the red zone hut and were kept from having any contact with people in the village. There was no treatment for smallpox or for Ebola. You went into the red zone, you got food and water, and you either survived or you didn’t. After the survivors emerged from the hut, the hut was burned. This was on-site disposal of biohazardous corpses, the same thing the Doctors did when they buried infected corpses next to the camp.

The virus is still flickering in Kenema, but the great fire has died down. Sierra Leone is getting a thousand new Ebola cases a month, a number that is dropping rapidly. The virus is active in Kono, an area to the north of Kenema. The schools of Sierra Leone are closed. All over the country there are roadblocks, where soldiers and police officers point a digital thermometer at your forehead and ask you questions about where you’ve been and where you’re going.

As a person talks, extremely fine, invisible drops of saliva are sent into the air around the person’s mouth, and the drops can drift up to six feet.

Testing blood saves lives, she said, because every time you can identify someone who has Ebola, you can isolate that person in a biocontainment ward, and so you can prevent that person from spreading the virus to others and creating more chains of transmission. There was no medical countermeasure to the virus, no modern medical defense. The only way to stop the virus was to stop people from giving it to other people, she said.

“In the fight with infectious disease we see death all the time, and we wonder why it happens. We’re all trying to understand our place in the universe and why we’re here. Khan’s death left me with a feeling that we just have to do more, and that men like him can’t be lost in vain.”

It may have been shivering, or it may have been the agonal stage of death from Ebola infection, the moment when the person dies with shaking or tremors. Brantly’s shivering continued, while Dr. Mobula reported that his temperature had started to drop. In fifteen minutes it fell from 105 down to 100—from fatal range down to a mild fever. The shaking went on for half an hour, gradually decreasing, and finally it stopped. It was now thirty minutes after the drug had started entering his bloodstream. Brantly sat up in bed. Just then, Plyler put his phone up against the screen in the window and took a picture of Brantly—his mouth is open, his eyes are sunken and half closed, but he looks very much alive.

If the virus were to amplify itself in the urban population of Lagos, the city could erupt in a viral equivalent of a nuclear detonation. Sawyer had close contacts with seventy people while he was dying in Nigeria, any of whom could have caught the virus from him and spread it to others. Fast, decisive action by Nigerian health authorities and foreign doctors managed to break the chains of infection that had started traveling out of Patrick Sawyer. Dr. Stella Adadevoh, who had prevented Sawyer from leaving the hospital, died of Ebola afterward; she is now regarded as a national hero for stopping the virus from spreading more widely in Nigeria.

None of the scientists, doctors, officials, or camp managers knew that Khan had been reading up on the experimental anti-Ebola drugs and vaccines, was familiar with the data on them, and considered ZMapp to be his first choice for treatment. It is being reported here for the first time.

“With the caveat that we are in the area of total speculation—off the map, there be sea monsters here—there is a growing body of evidence that viral therapy with antibodies works by killing infected cells. This makes sense since you are stopping the factories from churning out virus rather than just killing whatever comes out of the factories.” Bomb the factories that make the bombs, and you stop the bombs from being made.

At some point, people just got it,” Lina Moses said, months later. The Kissi villagers in the Makona Triangle were the first to understand the truth: Ebola wasn’t a fiction or a plot by foreigners, it was a communicable disease. People in the Makona Triangle learned the signs and symptoms of the disease. They avoided contact with anybody who looked like they might have the disease. They stopped going to funerals. In addition, they began sending their loved ones to the Doctors’ camps. And eventually the same thing happened all over West Africa. “What they came to understand is that they cannot take care of the people they love,” Lina Moses continued. “They have to surrender their infant, their spouse, or their beloved grandmother to an isolation ward in order to save the rest of their household. I think I would have a really hard time doing that in the same situation. When the stakes are your life and the lives of your family members, you figure things out pretty fast.”

At one village, Wolz and her driver were told they couldn’t go in at all, because the village had isolated itself from the world. “It was like something out of the past,” Wolz said. “They weren’t going to burials, they stopped kissing each other, they weren’t touching each other. Behavior changes.” “This is how all outbreaks end,” Armand Sprecher, the Doctors’ official in Brussels, said. “It’s always a change in behavior. Ebola outbreaks end when people decide they’re going to end.”

The Ebola war wasn’t won with modern medicine. It was a medieval war, and it went down as a brutal engagement between ordinary people and a life form that was trying to use the human body as a means of survival through deep time. In order to win this war against an inhuman enemy, people had to make themselves inhuman. They had to suppress their deepest feelings and instincts, tear down the bonds of love and feeling, isolate themselves from or isolate those they loved the most. Human beings had to become like monsters in order to save their human selves.

She didn’t have any protective gear, so she created a bio-hazmat suit out of plastic garbage bags. She tied garbage bags over her feet and legs, put on rubber boots over the bags, and then put more bags over her boots. She put on a raincoat, a surgical mask, and multiple rubber gloves, and she covered her head with pantyhose and a garbage bag. Dressed this way, Fatu Kekula set up IV lines for her family members, giving them saline solution to keep them from becoming dehydrated. Her parents and sister survived; her cousin died. And she herself remained uninfected. Local medical workers called Fatu Kekula’s measures the Trash Bag Method. All you needed were garbage bags, a raincoat, and no small amount of love and courage. Medical workers taught the Trash Bag Method, or variants of it, to people who couldn’t get to hospitals.

What would it be like if a Level 4 virus event occurred and the Ancient Rule arrived in the supercity of New York? It wouldn’t take much to produce the Ancient Rule in New York City. A dry virus with high mortality that infects people through the lungs. No vaccine, no medical treatment for the virus. If you take the subway, if you ride in an elevator, you can be infected, too. If the Ancient Rule came to New York City, we can imagine people lying facedown on the street or in Central Park, crowds staring and hanging back. People begging for help, no one willing to help. Police officers wearing full PPE gear. People needing ambulances. No ambulances. Hospitals gone medieval. Medical staff absent, dying, overwhelmed. All hospital beds full. People being turned away on the street from Bellevue Hospital. Medical examiner facilities gone hot as hell and crammed with corpses. Nobody in their right mind would enter a New York City hospital during a time of the Ancient Rule. Transportation frozen. Food supplies dwindling or absent. Schools closed. People avoiding supermarkets for fear of contagion. Prophets and visioners predicting the future and offering cures. People leaving the city, bringing the virus with them. Airports infective, flights canceled. Parents giving care to their sick children in apartments, at home. If someone in a family got sick, there would have to be one designated caregiver, a person willing to sacrifice their life in an attempt to give care to a loved one....

“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.”

If viruses can change, we can change, too.