Lessons from Ebola

In Richard Preston’s Crisis in the Red Zone, which made WORLD’s short list for the 2019 Book of the Year in the Understanding the World category, we get a page-turning account of the 2014 Ebola outbreak in West Africa. With the current spread of the novel coronavirus, it’s a good time to read his authoritative account of a new virus strain that invaded the world. The author, in chilling detail, shows how Ebola exploited “the deepest and most personal ties of love, care, and duty” to spread and amplify across the world.

Preston essentially predicted what is happening now, concluding his story by showing how unprepared the wider world was for a potential Ebola pandemic, and how much we have to thank healthcare workers in Africa for their sacrifices to prevent the wider spread of this highly contagious virus. We might forget that in 2014 epidemiologists forecast that the world could face 1.4 million Ebola cases by the end of that year. The African health workers portrayed in this book, many of them Christian, were part of why that didn’t happen.

As new viruses continue to morph and jump to humans, Preston warns that the world’s health systems have little capacity for large-scale isolations and treatment in a pandemic, which we saw as China rushed to build new hospitals to isolate its thousands of COVID-19 patients.

In the following excerpt, Preston narrates how a new strain of Ebola that would eventually kill thousands exploded from a 2014 funeral in Sierra Leone for Menindor, a traditional healer. It’s an unfolding horror film that will have you following the Centers for Disease Control and Prevention’s encouragement in 2020 to regularly wash your hands with soap and water as we pray for this new virus to die down. —Emily Belz

FLASH

KPONDU, SIERRA LEONE

April 8–10, 2014

Menindor’s sister and their mother had been caring for Menindor in life, and now they cared for her in death. After they had washed the body internally with an enema, they washed the outside of it with water. As they poured water over the body, the women may have collected the dirty water in a container such as a plastic laundry tub. Maybe they didn’t save the wash water they poured over the body. We simply don’t know.

I was in Kenema doing research for this book during the time when the crisis was receding, and one evening I was drinking a beer with a Sierra Leonian public health expert named Macmond Kallon, and he told me something I hadn’t heard before. Kallon had been working for the World Health Organization, visiting villages in the countryside around Menindor’s village, searching for people with Ebola and trying to get them into treatment centers to keep them from spreading the disease to others.

“The whole secret of the transmission of Ebola,” Kallon said, “is that you wash the body with water, and then the water is collected and used again.” The wash water from the corpse was carefully stored in a container. Then family members would use the water in a ceremony of grief and remembrance. “If you are the son of the dead person, you wash yourself with this same water, the water that washed the body,” Kallon explained. “After that, the daughter washes herself with the same water that the son used.” The washing ceremony was sometimes done in a grove of sacred trees, a patch of old forest. It was a type of ceremony similar to the one in which mourners ate a meal of the deceased person’s favorite foods while sitting next to the body of the deceased person in a forest. During the water ceremony, family members sometimes drank the wash water, Kallon said. It was a way of bringing the essence of the deceased person into themselves.

Ebola victims sweat profusely. The sweat glands pour out vast numbers of Ebola particles mixed with perspiration. The sweat clings to the skin and evaporates, leaving a film of Ebola particles behind. More sweat comes out, and more particles build up on the skin. By the time a person dies of Ebola disease, the corpse is painted with Ebola particles. There can easily be ten million Ebola particles sitting on a square inch of the corpse’s skin. Only one particle can cause an infection in another person. Ebola particles are quite tough as long as they are kept moist. Experiments have revealed that Ebola particles can stay potent for up to seven days while they’re sitting on the skin of a decaying corpse.

Thursday, April 10

Menindor’s funeral was held two days after she died. At least two hundred people showed up for the funeral, most of them women and young girls, and their grief was dramatic. Menindor lay on a bier, wrapped in fine cloth, her face and perhaps her arms and hands exposed to view. The mourners wept over her body, caressed her face, embraced her. As people touched the body, Ebola particles on the body’s skin were transferred to the mourners’ skin and clothing, especially to their hands. The mourners touched and hugged one another during the funeral, and they wiped tears from their eyes with their fingers. It was a huge crowd, moving around the bier of Menindor, expressive, churning, torn with loss.

I remember when my father died. I was with him at the time. My mother was there, too. As his breathing settled down, my mother held him close, and I put my arms around my mother. Then, after a few moments, I reached out and placed my hand on my father’s face, feeling his skin, still warm to the touch, my father, as the life went out of him. I couldn’t help but touch him as he went away. 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.

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.

If a single, well-formed particle of Ebola lands on the wet membrane of a person’s eyelid, it can slip through the membrane in seconds, entering a tiny blood vessel. From there the particle is pulled into the system of veins that lead toward the heart. The particle is a tiny thread of flotsam, jiggly and rubbery, flipping and flopping and twisting in the currents of the blood. It bumps against red blood cells but slides off them, doesn’t stick to them. If the particle were the size of a small shred of spaghetti, then a red blood cell would be the size of a dinner plate. The Ebola particle passes through the heart and lungs, traveling in the flow of the blood, and it enters the system of arteries, which lead away from the heart to all parts of the body. Sixty seconds after the Ebola particle has landed on the person’s eyelid it can be anywhere in the person’s body.

Eventually, somewhere in the person’s body, the particle sticks to a cell. The core of the particle gets pulled inside the cell. Now one Ebola particle is sitting inside one cell in the person’s body. At this point, the person may be doomed.

Inside the cell, the core of the Ebola particle falls apart. Its RNA, its genetic code, comes spooling out of the particle’s broken core, like thread whirling loose off a spindle. Next, the code takes command of the cell’s machinery and forces the cell to start making copies of the Ebola particle. Eighteen hours later, the cell is oozing newborn threads of Ebola, which grow out of the cell like hair, break off, and are carried away in the bloodstream. Each infected cell spits out up to ten thousand new Ebola particles. The particles end up everywhere in the body, infecting more cells, and each cell spits out thousands more Ebolas. This is known as extreme amplification of a virus. Soon the body is flooded with particles, and the person’s immune system collapses. At the time of death, vast numbers of cells all through the person’s body are converting themselves into Ebola particles. Ebola particles are made entirely out of human material: Ebola is an anti-human metamorphosis of the human form. The amplification of Ebola virus in the human body is one of the dark wonders of nature.

After Menindor’s funeral in Kpondu Village, the mourners returned to their villages elsewhere in the Triangle, where eventually some of them got sick. Those who loved them gave them care, and the virus moved to the caregivers, traveling along chains of duty and affection. The Ebola parasite got into a human network of affection and care, the ties of humanity that join each person ultimately to every other person on earth.

Some of the infected individuals sought help elsewhere, help from doctors and hospitals, from family members, from healers, and in different nations within the Makona Triangle or outside the Triangle. The network of human connection, going hot with a virus, extended into the cities of West Africa. The funeral of Menindor appears to have been a central, germinal event in what would become a full-scale epidemic of Ebola in the human species, the most destructive, fast-moving expansion of any lethal infectious agent during the past hundred years.

When epidemiologists finally learned about Menindor’s funeral and followed the chains of infection that emerged from the funeral, they found that at least 365 cases of Ebola could be traced back to the funeral. Menindor’s funeral set off chains of infection running in all directions, into Liberia, into Guinea, and toward Kenema Government Hospital, seventy miles away. The chain reaction had begun when a small boy touched an animal, possibly a bat, and a few particles of Ebola crossed the uncertain boundary that separates the body of a human being from the rest of the natural world.

Menindor’s funeral set off chains of infection running in all directions, into Liberia, into Guinea, and toward Kenema Government Hospital, seventy miles away.

Seven weeks after the parasite jumped out of nature and amplified itself in the boy, it entered Ms. Sia Wanda Koniono of Kpondu village, perhaps when she was riding in a jitney bus and bumped up against a sick passenger. She died on March 3 and was buried near Kpondu. Twenty-eight days later, on the first of April, the email sent by Jacob Maikere reporting Ms. Koniono’s death and burial went unnoticed by Humarr Khan and his team.

If Khan’s team had seen the report and had realized its significance—that Ebola was already in Sierra Leone, and was active in Kpondu, then it seems certain that they would have sent a surveillance team to Kpondu village to find out what was going on. The team would have arrived in Kpondu shortly after April 1. They likely would have found Menindor dying of Ebola in her bedroom.

If the Kenema team had discovered Menindor, they might have been able to get her into isolation, thus protecting people from exposure to Ebola. The Kenema team also might have been able to prevent a large, public funeral for Menindor from taking place. If Menindor’s funeral hadn’t happened, would Ebola virus have expanded into the world in racing chains of infection? Would the outbreak have gone so far and so deep? Would Ebola have reached Dallas, Lagos, and New York? If Menindor had been found in time, a hot seed of the epidemic might not have sprouted, and the outbreak might have been more local and more manageable.

Maybe or maybe not. We will never know, because this is not the way reality played out. And this is not to say that Humarr Khan and his team are at fault for anything. They are not at fault. It is to say that history turns on unnoticed things. 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 is not a thing but a swarm. Ever since a few particles of Ebola had slipped into the boy, the virus had been copying itself in ever larger numbers of people. It was a vast population of particles, different from one another, each particle competing with the others for a chance to get inside a cell and copy itself. As the particles copied themselves, there were errors in copying, and slightly different kinds of Ebola emerged in the swarm. You could imagine the virus as a school of fish, with each particle of Ebola a fish. The fish were swimming, and as they swam and multiplied they changed, until the school had many kinds of fish in it and was growing rapidly in size, with some kinds of fish better at swimming than others and with sharper teeth.

By the time Menindor caught the virus around March 26, the virus that had originally infected the little boy had mutated into several different kinds of Zaire Ebola. The virus had been chaining through people, crushing their immune systems, exploring the body’s defenses, and it had begun to adapt to the human species. Sometime in early March, a new kind of Ebola arose in the Makona Triangle. This mutant Zaire Ebola was four times better at infecting human cells. The mutant had a special affinity for human cells. It was a fish with sharper teeth. Menindor got infected with the mutant, and it killed her. The mutant came out of her body in death and was spread through her funeral.

Ebola is not a thing but a swarm.

The change in Zaire Ebola happened in just one letter of its genetic code. The virus that was spread at Menindor’s funeral, the mutant, the changed Ebola, is officially named the A82V Makona Variant of Zaire Ebola. In this book it will be referred to simply as the Makona strain or the hot Makona. Scientists think it first arose as a single mutant particle of Ebola in the body of some unidentified person who lived near or in the city of Guéckédou, Guinea. That one mutant particle of hot Makona, that one fish with sharper teeth, multiplied to vast numbers in the victim’s body. Then, somehow, the hot Makona strain got to Menindor. She almost certainly caught it from one of her patients. As of this writing, however, many questions about the hot Makona remain unanswered.

The Makona strain really gets into human cells easily. The strain may be able to spread through a person’s body faster and more powerfully than any other kind of Ebola—but this has not been proven. The Makona may be more contagious than any other Ebola, easier to catch. It could be hotter—more lethal—than any other filovirus, even hotter than Zaire Ebola. We really don’t understand the exact characteristics of the Makona strain. But by now there is quite a bit of evidence that the Makona strain is the most contagious and devastating kind of Ebola that’s yet appeared.

In the funeral of Menindor we are seeing something that resembles a high-speed movie displaying the first instants of a nuclear explosion. We are looking into the core of the expanding fireball right at the start of detonation. The funeral produced an unseen biological flash of a new virus, and the virus began explosive amplification in the human species.

Ninety miles away, at the Kenema hospital, nobody saw the flash, nobody was aware of it. The staff of the Kenema hospital didn’t know that something had happened that would lead to the deaths of many of them. Nobody anywhere noticed the movement of the mutant virus as the Makona strain began to spread in chains of infection, chains that branched into more chains and more branches. The hot Makona had started chaining its way toward every human body on earth, a biological wildfire growing in the human species. While much remains unknown about the hot Makona, there is no doubt that by the first day of April it had become the new lord of the strains.

Excerpted from Crisis in the Red Zone by Richard Preston. Copyright © 2019 by Richard Preston. Excerpted by permission of Random House, A Penguin Random House company. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.