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

by Richard Preston

This was nothing very unusual. It looked like a typical case of adult cerebral malaria, or malaria of the brain, a disease which is sometimes called blackwater fever. Blackwater fever causes patients to bleed into their eyeballs, to urinate brown or black blood, and to have hemorrhages from other openings of the body, and it causes brain damage, coma, and death. Sister Beata didn’t waste any time trying to diagnose the woman’s malady. Her goal was to deliver the woman’s child and try to save two lives.

She developed projectile vomiting, which is also called rocket vomiting, in which the stomach contracts violently and the vomitus is ejected up to two meters, or six feet, through the air. The vomitus would have ended up on the bed, on the floor, even perhaps on the walls, and certainly on any nurses who were giving her care.

As the linings of the intestines decayed, blood began leaking from the necrotic tissue, filling the colon with blood. The blood became discolored and, eventually, when the colon was full, the blood was expelled. This was a form of profuse hemorrhage. A rash, consisting of red spots mixed with red bumps, spread around her torso. The red spots, called petechiae, were small hemorrhages occurring inside her skin.

a mathematical pattern. The pattern of the interlocking proteins in a virus is far more complicated than a snowflake. The protein capsule is sometimes wrapped in an oily membrane. Inside the capsule there is a small amount of DNA or RNA, the molecules that contain the genetic code of the virus. The genetic code is the virus’s operating system, or wetware, the complete set of instructions for the virus to make copies of itself. Unlike a snowflake or any other kind of crystal, a virus is able to re-create its form. It would be as if a single snowflake started copying itself as it falls, and those copies of the snowflake copy themselves, creating ever-growing numbers of identical copies of the first snowflake, until the air is filled with falling snow, and each flake is a perfect replica of the first flake.

When a virus starts copying itself strongly and rapidly in a host, the process is called virus amplification.

If an Ebola particle were the size of a real piece of spaghetti, then a human hair would be about twelve feet in diameter and would resemble the trunk of a giant redwood tree.

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.

This ocean of viruses in the world of living nature is known as the virosphere. The virosphere includes all viruses as well as infective proteins called prions. The biosphere, as distinct from the virosphere, is the universe of organisms that are made of cells. The biosphere includes everything alive, from tigers to black slime on rocks. All living organisms in the biosphere are made of cells—single-celled organisms and multicellular organisms alike.

In the months after its emergence in Meliandou, the disease kept spreading. In a village called Dandou, which is a fifteen-minute drive by motorbike from Meliandou, a man got sick. He was a relative of the midwife of Meliandou, the woman who’d died in the Guéckédou hospital after she’d taken care of Émile’s mother and grandmother. The man realized he was dying, and he asked his family to carry him into a patch of sacred forest. They placed him on the ground under the trees, where he died surrounded by his loved ones. Afterward, following local tradition, the man’s friends and family members took turns lying next to his body in the forest. They embraced the body, wept over it, and ate meals next to it during which they served foods that the man had liked. This was a way of remembering the man and cherishing their love for him. The disease attacked some of the mourners afterward.

The French investigators had learned that some of the patients had had hiccups. This detail really caught their attention. Hiccups are a classic sign of Ebola virus disease.

Nipah is a bat virus that causes personality changes and liquefaction of the brain. Nipah is only moderately infectious, but it gets into the lungs, and there is a certain alarm among experts that the code of the virus could change and turn the virus into a sort of brain-destructive neurological cough that travels in the air. There is no vaccine or treatment for Nipah disease.

Over the years, as Doctors Without Borders slammed down Ebola successfully, a widespread view developed among public health experts that Ebola wasn’t much of a problem for the human population of the world and never would be. It is fair to say, however, that nature often does whatever is necessary in order to make the most number of experts wrong.

The first principle of warfare against an emerging virus is to know where it is moving. Yet

Lina Moses was having trouble getting her email. The Internet connection in Kenema was bad, and so she didn’t see the email in question. The report seemed to say that a woman got Ebola in Guinea, died in Guinea, and was buried in Guinea. It stated that the woman’s dead body was taken to “Gbandu,” but the report did not say that Gbandu is in Sierra Leone. In fact, there is a village in Guinea called Gbandou. Gbandou, Guinea, is three and a half miles from Kpondu, Sierra Leone. And the name of Menindor’s village in Sierra Leone has four different spellings, Kpondu, Gbandu, Koipondu, and Koipind. How could anybody guess that Gbandu and Koipind are the same village, and are in Sierra Leone? This illustrates the nightmare of identifying villages in the Makona Triangle.

Small, hidden events can have ripple effects, and the ripples can grow. A child touches a bat…a woman riding on a bus bumps against someone who isn’t feeling well…an email gets buried…a patient isn’t found…and suddenly the future arrives.

Ebola virus is known to be nearly one hundred percent fatal for pregnant women and their unborn babies. The virus typically kills the baby inside the womb, and triggers flooding hemorrhages from the birth canal as the baby is being born. The baby, itself infected with Ebola, is either stillborn or dies shortly after birth. This aspect of Ebola disease has been

known to doctors since 1976, when Sister Beata, the midwife of Yambuku, delivered at least two babies during hemorrhagic childbirths. It has also been known since the death of Sister Beata following those deliveries that Ebola virus is extremely dangerous for medical caregivers who come into contact with blood or body fluids of an Ebola-infected pregnant woman during childbirth.

Smallpox virus is transmitted from person to person through the air. The particles are embedded in microscopic, invisible drops of moisture that come out of an infected person’s mouth when the person is talking or simply breathing. Smallpox is also easily transmitted through contact with pus and scabs.

Brantly had had Ebola disease then; he had been infective. 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. Had an unseen fleck of the virus landed in her eyes, in her mouth, on her skin?

Viruses more powerful and dangerous than Ebola were going to emerge in the future, and medical people were going to have to deal with them. “If

The director of the CDC, Dr. Tom Frieden, saw the news reports and called Dr. Anthony Fauci, the head of NIAID—the NIH institute that runs the Integrated Research Facility at Fort Detrick. Frieden was upset, and he asked Fauci what was going on in Africa with this NIH researcher and this NIH drug. Anthony Fauci was taken quite by surprise. It seems he hadn’t known anything about it. If an experimental, unlicensed, untested drug is supplied by the NIH and is provided to a patient by an NIH employee, any decision to give the drug to the patient must be handled by top-level administrators at the NIH and must be overseen and authorized by the Food and Drug Administration. It seemed that Lisa Hensley had broken all the rules. The leaders of the NIH knew next to nothing about her. She was a lower-level scientist who’d been working at the agency for only a few months. The heads of the NIH began asking, in effect, Who is this Lisa Hensley person and what the hell did she do? Whoever she was, she seemed to have gone rogue.

at the NIH hospital in Bethesda, Maryland, for treatment, and survived. One of her principal physicians, who spent long hours at her bedside, was Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases.

The next Tuesday, he walked along the High Line—a park that follows an elevated train track in Manhattan—and drank coffee at a café. He visited a food shop and ate meatballs, he rode the subway, he went bowling. On

“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.

In a town in Liberia, a young woman named Fatu Kekula, who was a nursing student, ended up caring for four of her family members at home when there was no room for them in a hospital—her parents, her sister, and a cousin. 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.

At the same time that Ted Diehl was figuring out what made the Makona strain so dangerous, a researcher named Jonathan K. Ball, at the University of Nottingham, in England, and colleagues of his, discovered something equally disturbing about the Makona strain. It didn’t infect bat cells as well, while it infected human cells much better. In other words, the Makona strain is a humanized Ebola. The Makona strain understands people better than does any other kind of Ebola.

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. Wealthy people spending money like water trying to save themselves; the poor and disadvantaged, as always, bearing the worst of it. If there is a vaccine or drug that can help, there will be corruption. Companies and individuals hoarding vaccine, selling it at sky-high prices.

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.