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Inferno
A Doctor's Ebola Story
By Steven Hatch St. Martin's Press
Copyright © 2017 Steven Hatch
All rights reserved.
ISBN: 978-1-250-08514-6
CHAPTER 1
THE VESTIBULE
A screaming comes across the sky. It has happened before, but there is nothing to compare it to now.
— Thomas Pynchon, Gravity's Rainbow
This is a horror story. And as if someone from central casting were pulling the strings, this horror story begins with a small child happily playing right outside his home.
Meliandou is a small village of a few hundred inhabitants living in approximately thirty rustic dwellings in the hinterlands of Guinea, a satellite of the city of Guéckédou, a place to which the villagers, mostly farmers, come to sell their produce in the Nzérékoré Region, the easternmost province of a country shaped almost like an apostrophe that lost its footing in the middle of a sentence and was falling forward. Meliandou's North American equivalent would be described as "sleepy" and perhaps "idyllic." Although it would be naïve to think that Meliandou's people have lived a content, pastoral existence for centuries or even decades, as of the early twenty-first century, a quiet kind of peacefulness could be found there.
Emile Ouamouno was the beneficiary of this relative prosperity. The child of Etienne and Sia, Emile was growing up as children do in a relatively sheltered environment, exploring the natural world around him, which in the depths of the West African rain forest provided no end of wonders for a curious two-year-old. A picture of the three of them can be found on the Internet. Although they aren't smiling, one gets the sense that they are satisfied with their lives. They're an unmistakably beautiful family. Sia is on the right, her left hand on her hip, wearing an abstract-patterned light dress, with long white earrings and a yellow bead necklace. Her hair is close cropped. Etienne occupies the center, wearing a red-and-black soccer jersey. And Emile sits upright, staring into the camera, held in the crook of his father's right arm, eyes wide, the chubby cheeks of toddlerhood not yet dissipated. The graininess of the picture makes it look like it could have been taken in the 1960s, but it is from 2013.
Along with other children, Emile used to frequent a large tree at the periphery of the village. The tree was a natural jungle gym, with a hollow at its center large enough for a grown man to walk inside and even climb up into. By the news reports, the kids used to love playing around the tree. Again, you can find pictures of this tree in a few seconds with a Google search. It provided a natural setting for children to spend their afternoons doing what kids should do, especially a child of Emile's age.
It wasn't only children who utilized the tree for its size and the protection it offered. Farther up in the hollow, a nest of Angolan free-tailed bats had quietly taken up residence. The bats belong to the insect-feeding species Mops condylurus, and they are extremely common throughout much of sub-Saharan Africa. Their droppings would fall to the ground and mingle with the soil. With the heat of the jungle in the dry season, you would hardly have noticed the guano at all. And nobody did. Certainly the children didn't, focused as they were on the joys of playing. But it was this interface of child-bat-guano that may have led to Emile Ouamouno becoming Patient Zero of the West African Ebola outbreak in December 2013, the first spark in a fire that would rage for months and then years, a child who became the nexus of a tragedy in which thousands would die, thousands more would be maimed, and tens of thousands of others would feel its shockwaves without ever coming near the agent that transmitted such suffering.
* * *
The screaming first came across the sky in 1976. Quite remarkably, two simultaneous outbreaks took place hundreds of miles apart, one in the southern part of Sudan, the other in Zaire, the country we now call the Democratic Republic of the Congo, or DRC. The Sudan outbreak led to nearly three hundred infections, and half of the patients died. The Zaire epidemic led to about the same number of infections, but in this outbreak nine of every ten patients died. The identification of this strange and very deadly new virus would take place in state-of-the-art facilities designed to deal with the most lethal pathogens on the planet — so-called Biosafety Level 4 laboratories. In short order Ebola would develop a reputation among the scientists who studied it as the most fearsome of a small group of truly terrifying infectious agents.
Ebola became one of a number of viruses that would earn the moniker of "emerging infectious diseases," although the term itself indicates the hubris by which Homo sapiens sometimes regard our world. The virus had hardly "emerged"; it's just that we finally happened to stumble upon it and identify it for what it was. What we now call Ebola has without any doubt been around for thousands of years, probably tens of thousands. Although much of what we know about Ebola is provisional and therefore subject to wide ranges of interpretation, we're reasonably sure that the virus has circulated among fruit bats for millennia in much the same way that cold viruses circulate among humans — that is, it might make them sick, but not ever sick enough to do any real harm. A virus has an interest in not making its host too sick, because then it can survive in a happy equilibrium by making copies of itself and continuing to survive as long as it has plenty of hosts to which it can spread. It has no interest in killing its primary host — or at least killing it quickly — since then it can't spread and will ensure its own demise. But when a virus jumps a species, and it happens to be deadly to that other animal, all bets are off.
The fruit bat may be Ebola's "natural reservoir"— the creature in which the virus finds its primary home — although, again, nobody is completely certain of that. Unlike many other viruses, whose place in nature scientists have been able to deduce from careful field studies, Ebola for all its ferocity has been something of a shy predator, disappearing back into the jungle as quickly as it materializes, making itself seemingly invisible despite decades of animal testing conducted on the creatures who live at the site of the outbreaks. It wasn't until 2005 — after nearly three decades of seriously funded, high-level research — that scientists were able to spot the genetic signature of Ebola in the blood of fruit bats, which provided indirect evidence that the bats were its natural home. Four years later, Ebola's sibling, the Marburg virus, was isolated in fruit bats. Thus far, three species have been proven to possess the virus: the hammer-head bat, or Hypsignathus monstrosus; the little collared fruit bat, or Myonycteris torquata; and finally, the elaborately named Franquet's epauletted fruit bat, or Epomops franqueti. Fruit bats are fairly endearing creatures, with humanlike faces and a soft fur on all but their wings. They are commonly called "flying foxes" based on their resemblance. But the bats believed to be nesting in the tree in Meliandou were not fruit bats at all and aren't especially cute. Yet the close proximity of Mops condylurus to Emile Ouamouno seemed suggestive, although subsequent research on bats captured in the area found no evidence of current or prior infection. The bat-origin hypothesis could not be confirmed, becoming another tantalizing clue in a complex puzzle, and much about how the virus behaves in its natural environment remains completely unknown.
Ebola got its name by a slight bending of the rules of virus nomenclature on the part of the scientists who discovered it. The Zaire outbreak in 1976 began in a Catholic mission hospital in a village known as Yambuku. The hospital saw the first patients of this distinct and novel disease, more than twenty in all. Nearly all of them died, which led the staff doctor to alert the Zairean Ministry of Health, who sent a team to investigate and found the hospital closed because the staff themselves had become sick. The medical staff too nearly all died. This was what prompted the government of Zaire to call for the international response that led to the collection of blood samples and eventual isolation of the virus. Traditionally, viruses such as these are named based on the location where the first cases are identified. Marburg's natural reservoir, for instance, is in Africa, but it is named after the German town where the first known human cases of the disease occurred, in animal workers handling African green monkeys. Similarly, at nearly the same time the patients in Yambuku were dying, a group of teenagers in a small town in Connecticut had become moderately ill with a disease that would eventually be proven to be bacterial in origin, but the scientists applied the same "viral" rule of naming it after the site of its discovery. The town's name is Lyme.
There were, however, some downsides to following the custom of naming this particular virus Yambuku, especially in a place like rural Africa. Stigmatization was a serious problem. A virus discovered in the late 1960s in a small Nigerian town led to its christening as the Lassa virus, with the consequence that the inhabitants of that place were treated with suspicion and hostility for years afterward. Of the international team, Dr. Karl Johnson, who served as the head of the Centers for Disease Control's Special Pathogens Branch, had proposed sidestepping this problem by naming the virus after a local river. He had done the same the decade before with a deadly virus that caused a disease known as Bolivian Hemorrhagic Fever, giving it the name of Machupo — a tributary of the Amazon. The team favored this approach. They looked on a map, saw a tributary of the Congo known as Ebola, and the name thus took. The name Ebola is from a local Bantu language, Lingala, and means "black river." It was hard to come up with a better name for it than that.
Ebola required another name as well — the class to which it belonged. Viewed under the scanning electron microscope, both Marburg and Ebola had a shape that was completely unlike that of any virus seen before. Most human viruses are roughly spherical in shape, whether HIV, measles, the Hepatitis A, B, and C viruses, and so on. One partial exception is rabies, which if contracted and left untreated is nearly 100 percent lethal, and is thus, along with untreated HIV, technically humankind's most deadly virus. Rabies has a shape that looks almost exactly like a bullet. But Ebola and Marburg have a long, tube-like structure that folds over on itself in erratic ways, each copy of the virus appearing to be slightly different from the next. Not long after Ebola's discovery, a group of scientists proposed the family name of tuburnavirus, from the Latin meaning "tubular virus." Instead, in the early 1980s, a symposium on Ebola and Marburg naming was held by the International Committee on Taxonomy of Viruses, the body in charge of providing names and classifications not only to Ebola and Marburg but to all viruses discovered in the world, so that there is some uniformity of nomenclature in the scientific literature. Shortly thereafter, a new proposal to call the family filovirus (from the Latin for "filamentous virus") was submitted to the committee. The concept was the same as that of the name tuburnavirus but was less of a mouthful, and the name stuck.
The mystery deepened. The Sudan outbreak of 1976 would prove to be an Ebolavirus, but although its behavior in humans was roughly similar to that of the Zaire strain — it was, indeed, a little less lethal — its structure was not identical. While the basic internal machinery of the virus was the same, the proteins that coated the surface of the virion were shaped differently. In the laboratory, antibodies that were highly specific for the virus from the Yambuku patients could not latch on to the virus from the Sudanese patients. However, less specific antibodies cross-reacted with both types. Thus, two strains of Ebola had been discovered that year: the Sudan Ebolavirus and the Zaire Ebolavirus. It was the latter that would reappear in Meliandou.
But in 1976, just as quickly as it had begun, the screaming abruptly halted. In 1979, a small outbreak occurred in the town of Nzara, the same location as the original Sudan outbreak. Nearly three dozen people were infected, and twothirds of them died. After that, however, human Ebola would not be heard from again for more than fifteen years. Then, starting in the mid-1990s, the virus would burst back in terrifying paroxysms that would affect not only Sudan and the now newly named DRC, but also Gabon, Uganda, and the Republic of the Congo. The outbreaks would return almost yearly up to the present day, and these governments in Central Africa would learn to maintain extreme vigilance against the disease.
The screaming then took an even more ominous turn. In 1989, an animal quarantine facility in Reston, Virginia, noticed some crab-eating macaques from the Philippine island of Mindanao — more than seven thousand miles away from Sudan or the DRC — had come down with an unexplained serious illness. Under the eyes of the electron microscope, it had the hallmark spaghetti-like appearance of a filovirus, and the nonspecific antibodies against Ebola lit up, which must have come as a serious shock to the scientists involved. Moreover, the disease was spreading inside the facility, as macaques from different shipments began to fall ill. This strongly implicated that the pathogen wasn't transmitting through direct creature-to-creature contact, as had all previous accounts of Ebola transmission.
You couldn't have scripted a more unsettling scenario: Not only had one of the world's deadliest viruses nestled itself into the United States, it was an airborne strain of the disease. And it was within a half hour's drive of the nation's capital. Because of this, several years later, when Richard Preston penned The Hot Zone in 1995, very little needed to be exaggerated for the book to live up to its subtitle: A Terrifying True Story. The core story of the Reston outbreak in the hands of a masterful writer such as Preston quickly turned The Hot Zone into an international best seller, and Ebola captured the popular imagination. At almost the same time, a more comprehensive and scholarly consideration of the subject of emerging infectious diseases (of which Ebola was one small chapter) had come out, and Laurie Garrett's The Coming Plague also catapulted to fame.
The only good news from the 1989 Reston outbreak was that it appeared not to cause disease in humans, as a half dozen of the workers involved in the incident were found to have antibody responses to the virus, even though they never became ill. The more sobering news, which wasn't much emphasized in The Hot Zone, was that the Reston Ebolavirus could be found almost halfway around the world from the previous outbreaks, and in a place where the citizenry travels much farther and with much greater frequency. It indicated there were biological threats out there of which we were only dimly aware, and they were capable of exploiting ways in which humanity was organized in the late twentieth century that might, at its worst, threaten civilization itself.
The release of The Hot Zone and The Coming Plague in 1995 couldn't have been more serendipitous, for in that year perhaps the scariest of Ebola outbreaks until then took place, when the virus made its first truly urban appearance in Kikwit, a city of around two hundred thousand people in the country then called Zaire. As with the initial outbreaks, more than three hundred people became infected; the case fatality rate was 80 percent. But the Kikwit outbreak did more than just boost sales and make publishers happy, for it got people thinking about what might happen if Ebola was discovered in a truly large African city — say, of one or two million people. Those cities, of course, have airports with international destinations. And by the late 1990s Africans were traveling more and more, and to every corner of the world.
* * *
Emile Ouamouno fell ill in late December 2013. Nobody knows what his precise symptoms were because hardly anyone who cared for him is left alive. He had a fever and may have had a headache. He reportedly had bloody diarrhea. Of course, dozens of diseases can cause bloody diarrhea, all of them considerably more common than Ebola, which had not been seen before in Guinea. This is a book about Ebola, but it is worth pointing out that infectious diarrhea remains among the biggest killers of children under the age of five in this part of the world. Baby Emile was much more likely to have rotavirus, enterohemorrhagic E. coli, non-typhoidal Salmonella, or Campylobacter, among many other organisms, than anything so exotic as Ebola. The global health community has made considerable progress in preventing such deaths, cutting the mortality rate in half over the past fifteen years. It's actually a great story that should be told to the public. Yet, despite this uplifting advance, more than half a million children annually still die of this largely preventable and treatable condition, which is virtually unheard of in the West.
(Continues...)
Excerpted from Inferno by Steven Hatch. Copyright © 2017 Steven Hatch. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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